CMS Pub. 100-16, ch. 21, § 50.6.10

42 C.F.R. §§ 422.503(b)(4)(vi)(F), 423.504(b)(4)(vi)(F)

An effective program to control FWA includes policies and procedures to identify and

address FWA at both the sponsor and FDR levels in the delivery of Parts C and D

benefits. An SIU is an internal investigation unit, often separate from the compliance

department, responsible for conducting surveillance, interviews, and other methods of

investigation relating to potential FWA. Depending upon the size of and resources

available within the organization, sponsors must either establish a specific SIU or ensure

that responsibilities generally conducted by an SIU are conducted by the compliance

department. Sponsors are not expected to perform law enforcement activities and may

refer all matters indicative of FWA to the NBI MEDIC or law enforcement.

SIU responsibilities should include:

• Reducing or eliminating Medicare Parts C and D benefit costs due to FWA;

• Reducing or eliminating fraudulent or abusive claims paid for with federal

dollars;

• Preventing illegal activities;

• Identifying enrollees with overutilization issues;

• Identifying and recommending providers for exclusion, including those who have

defrauded or abused the system to the NBI MEDIC and/or law enforcement;

• Referring suspected, detected or reported cases of illegal drug activity, including

drug diversion, to the NBI MEDIC and/or law enforcement and conducting case

development and support activities for NBI MEDIC and law enforcement

investigations; and

• Assisting law enforcement by providing information needed to develop successful

prosecutions.

SIUs must be accessible through multiple channels such as via phone, email, Internet

message submission, and mail. Sponsors must ensure that suspicions of FWA can be

reported anonymously to the SIU.

Sponsors must ensure that the SIU and compliance department communicate and

coordinate closely to ensure that the Medicare Parts C and D benefits are protected from

fraudulent, abusive and wasteful schemes throughout the administration and delivery of

benefits, both at the sponsor and FDR levels.