Inclusion and Consideration of Evidence of Fraud and/or Abuse

280.2 - Inclusion and Consideration of Evidence of Fraud and/or Abuse (Rev. 4278, Issued: 04-12-19, Effective: 06-13-19, Implementation: 06-13-19) The MAC shall inquire fully into the matters at issue by receiving, in evidence, the testimony of witnesses and any documents that are relevant to the claims at issue. If the MAC believes that evidence has been tampered with, it shall refer this documentation to either the medical review or the UPIC’s units for their follow-up. The MAC may receive evidence obtained and provided by the UPIC concerning fraud or potential fraud with respect to the claim(s) at issue. If the UPIC provides such evidence, it becomes part of the case file and must be made available for inspection by the appellant prior to the reconsideration. Evidence of this nature is to be evaluated to determine issues such as whether, in conjunction with other credible evidence, the services in question were actually provided or were provided as billed. NOTE: See §300.3 for additional information regarding fraud and abuse investigations.