CMS Pub. 100-18, ch. 9, § 50.6.10

(Chapter 21 - Rev. 109, Issued: 07-27-12, Effective: 07-20-12; Implementation: 07­ 20-12)

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.