How to Upload Documents via the OMHA e-Appeal Portal

49.2 – How to Upload Documents via the OMHA e-Appeal Portal Exhibit 50 – UPIC and I-MEDIC Fax Cover Sheet Exhibit 1 - Definitions (Rev. 10228; Issued: 07-27-20; Effective: 08-27-20; Implementation: 08-27-20) A Abuse Billing Medicare for services that are not covered or are not correctly coded. Affiliated Contractor (AC) A Medicare carrier, Fiscal Intermediary (FI), or other contractor such as a Durable Medical Equipment Medicare Administrative Contractor (DME MAC), which shares some or all of the Unified Program Integrity Contractor’s (UPIC’s) jurisdiction; Affiliated Contractors perform non-UPIC Medicare functions such as claims processing. B-C Carrier The Carrier is an entity that has entered into a contract with CMS to process Medicare claims under Part B for non-facility providers (e.g., physicians, suppliers, laboratories). DME MACs are those carriers that CMS has designated to process DME, prosthetic, orthotic and supply claims. Case A case exists when the UPIC or Medicare contractor BI unit has referred a fraud allegation to law enforcement, including but not limited to, documented allegations that: a provider, beneficiary, supplier, or other subject has a) engaged in a pattern of improper billing, b) submitted improper claims with actual knowledge of their truth or falsity, or c) submitted improper claims with reckless disregard or deliberate ignorance of their truth or falsity. Contractor Contractor includes all intermediaries, carriers, DME MAC, RHHIs, MACs, and UPICs. Centers for Medicare & Medicaid Services (CMS) CMS administers the Medicare program. CMS’ responsibilities include management of AC and Medicare contractor claims payment, managing UPIC, AC, and Medicare contractor fiscal audit and/or overpayment prevention and recovery, and the development and the monitoring of payment safeguards necessary to detect and respond to payment errors or abusive patterns of service delivery. CMS was formerly known as the Health Care Financing Administration (HCFA). Closed Case A FID case shall be closed when no further action will be required of the UPIC, or Medicare contractor BI unit by the law enforcement agency(ies) working the case and when the law enforcement agency(ies) has ended all its activity on the case. Note that even after the case is closed, there may still be administrative actions that the UPIC, or Medicare contractor BI unit will take. D-E Department of Justice (DOJ) Attorneys from DOJ and United States Attorney’s Offices have criminal and civil authority to prosecute those providers who de-fraud the Medicare program. Demand Bill or Demand Claim A demand bill or demand claim is a complete, processable claim that must be submitted promptly to Medicare by the physician, supplier or provider at the timely request of the beneficiary, the beneficiary’s representative, or, in the case of a beneficiary dually entitled to Medicare and Medicaid, a state as the beneficiary’s subrogee. A demand bill or demand claim is requested usually, but not necessarily, pursuant to notification of the beneficiary (or representative or subrogee) of the fact that the physician, supplier or provider expects Medicare to deny payment of the claim. When the beneficiary (or representative or subrogee) selects an option on an advance beneficiary notice that includes a request that a claim be submitted to Medicare, no further demand is necessary; a demand bill or claim must be submitted. F Federal Bureau of Investigation (FBI) Along with OIG, the FBI investigates potential health care fraud. Under a special memorandum of understanding, the FBI has direct access to contractor data and other records to the same extent as OIG. Fraud Fraud is the intentional deception or misrepresentation that the individual knows to be false or does not believe to be true, and the individual makes knowing that the deception could result in some unauthorized benefit to himself/herself or some other person. G-H I Intermediary The intermediary is a public or private agency or organization that has entered into an agreement with CMS to process Medicare claims under both Part A and Part B for institutional providers (e.g., hospitals, SNFs, HHAs, hospices, CORFs, OPT, occupational therapy, speech pathology providers, and ESRD facilities). Regional home health intermediaries (RHHIs) are those FIs that CMS has designated to process Medicare claims received from home health and hospice providers. J-K-L Local Coverage Determinations (LCDs) The LCDs are those policies used to make coverage and coding decisions in the absence of specific statute, regulations, national coverage policy, national coding policy, or as an adjunct to a national coverage policy. M Medicare Contractor (Benefit Integrity) Medicare contractors include all intermediaries and carriers that have not transitioned their benefit integrity work to a UPIC. Medicare Contractor (Medical Review) Medicare contractors include intermediaries, carriers and MACs. Misrepresented A deliberate false statement made, or caused to be made, that is material to entitlement or payment under the Medicare program. N Noncovered (Not Covered) Noncovered services are those for which there is no benefit category, services that are statutorily excluded (other than §1862 (A)(1)(a)), or services that are not reasonable and necessary under §1862 (A)(1)(a). O Office of Audit Services (OAS) The OAS conducts comprehensive audits to promote economy and efficiency and to prevent and detect fraud, abuse, and waste in operations and programs. OAS may request data for use in auditing aspects of Medicare and other Health and Human Service (HHS) programs and is often involved in assisting OIG/OI in its role in investigations and prosecutions. Office of Counsel to the Inspector General (OCIG) The OCIG is responsible for coordinating activities that result in the negotiation and imposition of Civil Monetary Penalties (CMPs), assessments, and other program exclusions. It works with the Office of Investigations (OIG), Office of Audit Services (OAS), CMS, and other organizations in the development of health care fraud and exclusions cases. Office of Inspector General (OIG) The OIG investigates suspected fraud or abuse and performs audits and inspections of CMS programs. In carrying out its responsibilities, OIG may request information or assistance from CMS, its Unified Program Integrity Contractor (UPIC), Medicare contractors, and QIOs. OIG has access to CMS's files, records, and data as well as those of CMS'scontractors. OIG investigates fraud, develops cases, and has the authority to take action against individual health care providers in the form of CMPs and program exclusion, and to refer cases to the DOJ for criminal or civil action. OIG concentrates its efforts in the following areas: • Conducting investigations of specific providers suspected of fraud, waste, or abuse for purposes of determining whether criminal, civil, or administrative remedies are warranted; • Conducting audits, special analyses and reviews for purposes of discovering and documenting Medicare and Medicaid policy and procedural weaknesses contributing to fraud, waste, or abuse, and making recommendations for corrections; • Conducting reviews and special projects to determine the level of effort and performance in health provider fraud and abuse control; • Participating in a program of external communications to inform the health care community, the Congress, other interested organizations, and the public of OIG's concerns and activities related to health care financing integrity; • Collecting and analyzing Medicare contractor, AC, Medicare contractor, and State Medicaid agency-produced information on resources and results; and, • Participating with other government agencies and private health insurers in special programs to share techniques and knowledge on preventing health care provider fraud and abuse. Office of Investigations (OI) The Office of Investigations (OI), within OIG, is staffed with professional criminal investigators and is responsible for all HHS criminal investigations, including Medicare fraud. OIG/OI investigates allegations of fraud or abuse whether committed by UPICs, ACs, Medicare contractors, grantees, beneficiaries, or providers of service (e.g., fraud allegations involving physicians and other providers, contract fraud, and cost report fraud claimed by hospitals). The OIG/OI presents cases to the United States Attorney's Office within the Department of Justice (DOJ) for civil or criminal prosecution. When a practitioner or other person is determined to have failed to comply with its obligations in a substantial number of cases or to have grossly and flagrantly violated any obligation in one or more instances, OIG/OI may refer the case to OCIG for consideration of one or both of the following sanctions: • An exclusion from participation in the Medicare program or any State health care programs as defined under §1128(h) of the Social Security Act (the Act); or • The imposition of a monetary penalty as a condition to continued participation in the Medicare program and State health care programs. Offset The recovery by Medicare of a non-Medicare debt by reducing present or future Medicare payments and applying the amount withheld to the indebtedness. P Providers Any Medicare provider (e.g., hospital, skilled nursing facility, home health agency, outpatient physical therapy, comprehensive outpatient rehabilitation facility, renal dialysis facility, hospice, physician, non-physician practitioner, laboratory, supplier, etc.). For purposes of this manual, the term provider is generally used to refer to individuals or organizations that bill carriers, intermediaries, DME MACs, and RHHIs. If references apply to only specific providers (e.g., physicians), the specific provider will be identified. Q- R Quality Improvement Organization (QIO) The Peer Review Improvement Act of 1982 established the utilization and quality control peer review organization (PRO) program. The PRO name has changed to quality improvement organization. CMS contracts with independent physician organizations in each state to administer the QIO program. Their purpose is to ensure that the provisions of the Peer Review Improvement Act of 1982 are met. Under their contracts with CMS, QIOs are required to perform quality of care reviews of the medical services provided to Medicare beneficiaries in settings including, but not limited to: physician offices, acute care hospitals, specialty hospitals (for example psychiatric and rehabilitation hospitals), and ambulatory surgical centers. In the inpatient setting, QIOs also perform provider-requested higher-weighted DRG reviews for acute inpatient prospective payment system (IPPS) hospitals and long-term care hospital (LTCH) claims. Recoupment The recovery by Medicare of any outstanding Medicare debt by reducing present or future Medicare payments and applying the amount withheld to the indebtedness. Reliable Information Reliable information includes credible allegations, oral or written, and/or other material facts that would likely cause a non-interested third party to think that there is a reasonable basis for believing that a certain set of facts exists, for example, that claims are or were false or were submitted for non-covered or miscoded services. Reliable information of fraud exists if the following elements are found: • The allegation is made by a credible person or source. The source is knowledgeable and in a position to know. The source experienced or learned of the alleged act first hand, i.e., saw it, heard it, read it. The source is more credible if the source has nothing to gain by not being truthful. The source is competent; e.g., a beneficiary may not always be a credible source in stating that services received were not medically necessary. An employee of a provider who holds a key management position and who continues to work for the provider is often a highly credible source. The friend of a beneficiary who heard that the provider is defrauding Medicare may not be a particularly credible source; • The information is material. The information supports the allegation that fraud has been committed by making it more plausible, reasonable, and probable (e.g., instructions handwritten by the provider delineating how to falsify claim forms). • The act alleged is not likely the result of an accident or honest mistake. For example, the provider was already educated on the proper way to complete the form, or the provider should know that billing for a service not performed is inappropriate, or claims are submitted the same way over a period of time by different employees. Reliable evidence includes but is not limited to the following: • Documented allegations from credible sources that items or services were not furnished or received as billed; • Billing patterns so aberrant from the norm that they bring into question the correctness of the payments made or about to be made; • Data analysis that shows the provider's utilization to be well above that of its peers without any apparent legitimate rationale for this; • Statements by beneficiaries and/or their families attesting to the provider's fraudulent behavior; • Corroboration from provider employees (official and unofficial whistle blowers); • Other sources, such as prepayment and postpayment review of medical records; or • Recommendations for suspension by OIG/OI, FBI, Assistant U.S. Attorneys (AUSAs), or CMS, based on their finding that the provider has already received overpayments and continued payments should be made only after a determination that continued payment is appropriate. S Services Medical care, items, such as medical diagnosis and treatment, drugs and biologicals, supplies, appliances, and equipment, medical social services, and use of hospital RPCH or SNF facilities. (42CFR 400.202). In other sections of Medicare manuals and remittance advice records, the term item/service is used. However, throughout this manual we will use the term service to be inclusive of item/service. See §1861 of Title 18 for a complete description of services by each provider type. Suspension of Payment Suspension of payment is defined in the regulation 42CFR 405.370 as "the withholding of payment by the carrier or intermediary from a provider or supplier of an approved Medicare payment amount before a determination of the amount of overpayment exists." In other words, ACs or Medicare contractors have received processed and approved claims for a provider's items or services; however, the provider has not been paid and the amount of the overpayment has not been established. T-U-V-W-X Unified Program Integrity Contractor (UPIC) The UPIC is a contractor dedicated to program integrity that handles such functions as audit, medical review and potential fraud and abuse investigations consolidated into a single contract. T-U-V-W-X Exhibit 2 – Reserved for Future Use (Rev. 220, Issued: 08-24-07, Effective: 09-03-07, Implementation: 09-03-07) Exhibit 4 - Reliable Information - (Rev. 3, 11-22-00) Reliable evidence includes but is not limited to the following: • Documented allegations from credible sources that items or services were not furnished or received as billed; • Billing patterns so aberrant from the norm that they bring into question the correctness of the payments made or about to be made; • Data analysis that shows the provider's utilization to be well above that of its peers without any apparent legitimate rationale for this; • Statements by beneficiaries and/or their families attesting to the provider's fraudulent behavior; • Corroboration from provider employees (official and unofficial whistle blowers); • Other sources, such as prepayment and postpayment review of medical records; or • Recommendations for suspension by OIG/OI, FBI, Assistant U.S. Attorneys (AUSAs), or CMS, based on their finding that the provider has already received overpayments and continued payments should be made only after a determination that continued payment is appropriate. Exhibit 5 - Background Information When IRP is Questioned - (Rev. 3, 11-22- 00) Section 203(b)(1) of the Health Insurance Portability and Accountability Act of 1996 allows the federal government to pay a reward to individuals who report evidence of suspected fraud and abuse against the Medicare program. Implementing regulations, issued on June 8, 1998, were effective on July 8, 1998 and provide that a complainant may be rewarded up to 10 percent of the amount recovered, but not more than $1,000. Not everyone is eligible for the reward, though. To be eligible for a reward: • The information you give has to lead to a recovery of at least $100; • The suspected fraud must be acts or omissions that are grounds for the government to impose sanctions provided under certain provisions of the law; • There isn't another reward that you qualify for under another government program; • You must not have participated in the sanctionable offense with respect to which payment is being made; • If the person or organization is already under investigation; and • You are not an immediate family member or an employee of the Department of Health and Human Services, its contractors or subcontractors, the Social Security Administration, the Office of the Inspector General, a State Medicaid agency, the Department of Justice, the FBI, or any other federal, State, or local law enforcement agency at the time he or she came into possession, or divulged information leading to a recovery of Medicare funds. You'll receive a letter from us acknowledging that we have received your complaint. Some investigations take a long time to complete, and may take several months or years to resolve. You'll be notified by letter of your eligibility to receive a reward after the Medicare funds have been recovered. If you do receive a reward for this information you may be expected to pay any applicable state and federal taxes. 5.1 - Reward Eligibility Notification Letter - (Rev. 3, 11-22-00) Dear________________________________: You are eligible for a reward as part of the Medicare Incentive Reward Program for telling us about Medicare fraud and abuse. To claim your reward, please fill out the enclosed form and return it to [contractor information] in the enclosed envelope. You have one year from the date of this letter to claim your reward. In the case of death or incapacitation of the person reporting the potential fraud, a legal representative of that person may claim the reward on his or her behalf when evidence is submitted to justify the claim. If it is later found that you received the reward caused by your misrepresentation of the facts, all monies paid to you must be returned to Medicare. If you have questions, please contact [contractor information]. Sincerely, [Contractor Information] Enclosures 5.2 - Reward Claim Form - (Rev. 3, 11-22-00) [To be completed by contractor.] Provider/Supplier Name Case Number REWARD CLAIM FORM Date Dear [Contractor Information]: I am claiming the reward for providing information about Medicare fraud by filling out this form as it applies to me. My signature verifies that I am a proper recipient of the incentive reward or that I am the legal representative of the proper recipient of the reward. I also understand that the reward must be repaid by the recipient if it is later determined that the reward should not have been received. CLAIMANT INFORMATION Name________________________________________________ Street Address______________________________________ City, State, Zip code______________________________ Telephone Number____________________________________ Claimant (or Representative) Signature__________________________ REPRESENTATIVE INFORMATION If the intended recipient of the reward has become incapacitated or has died, his or her executor, administrator, or other legal representative may collect the reward on the individual's behalf or for the individual's estate. In addition to submitting this letter, please also submit certified copies of letters testamentary, letters of administration, or other similar evidence to show your authority to claim the reward. In the space provided below, please submit your name and the mailing address where the check should be sent if that address differs from the information stated above. Name________________________________________________ Street Address______________________________________ City, State, Zip code______________________________ Telephone Number____________________________________