Fraud and Abuse Investigations

300.3 - Fraud and Abuse Investigations (Rev. 4278, Issued: 04-12-19, Effective: 06-13-19, Implementation: 06-13-19) Any and all evidence used by the A/B MAC (A), (B), (HHH), or DME MAC to arrive at a determination or decision shall be placed in the appeals case file (copies are acceptable). Information in the case file shall be made available to an appellant upon request. Therefore, the MAC shall be aware that information placed in the case file is accessible to an appellant. The UPIC shall also understand that the MAC may not consider any evidence that has not been made a part of the case file. The UPIC and the MAC shall therefore exercise discretion when deciding whether to place any of the following information into the appeals case file: • The impetus behind a fraud and abuse investigation; • The name of the beneficiary or any other person lodging the complaint that triggers the fraud and abuse investigation; • Notes or transcripts of beneficiary interviews resulting from a fraud and abuse investigation; • Records or information compiled for law enforcement purposes during a fraud and abuse investigation; or • The name of a confidential source(s) when confidentiality has been promised by CMS in return for cooperation in a fraud and abuse investigation. Where the MAC relies upon any of the above information in order to deny a claim or to render a less than fully favorable determination or decision, then an appellant has a due process right to review this information. If information is kept out of an appeals case file for confidentiality reasons, it may not be relied upon to make a coverage decision or deny or reduce payment.