Documentation Guide List - Termination for Noncompliance

3028 - Documentation Guide List - Termination for Noncompliance With §§1866(b)(2)(A) and (C) (Rev. 1, 05-21-04) 3028A - Documentation Appropriate to All Cases (Rev. 1, 05-21-04) The RO uses the following to document recommendations for termination of a provider agreement pursuant to §§1866(b)(2)(A) and (C) of the Act: • Copy of the letter to the provider advising it of the recommendation for termination (include the certified mail return receipt); • Copy of Health Insurance Benefits Agreement, Form CMS-1561, filed by the provider and accepted for filing in the RO; • Copy of the Letter of Acceptance of Agreement forwarded to the provider; • All pertinent beneficiary complaints received; • All pertinent violation reports made by the intermediary, Social Security office, etc.; • Detailed reports of all pertinent intermediary efforts (i.e., dates, topic, reactions, results) and copies of related correspondence from the intermediary to the provider, including copies of any pertinent “provider letters” that may have been issued by the intermediary to the provider; • Intermediary report on the current payment status of the provider, e.g., suspended, reduced, in current payment status. If the recommendation is based on failure to file annual cost reports, this item may be included as part of §3028.C; • Detailed reports of all pertinent RO efforts (i.e., dates, topics, results, etc.) and copies of related correspondence from the RO to the provider; and • All pertinent letters (or detailed records of visits or phone calls) received by the intermediary or by the RO from the provider. 3028B - Additional Documentation - Charging for Covered Services and/or Refusing to Refund Incorrect Collections (Rev. 188, Issued: 04-26-19, Effective: 04-26-19, Implementation: 04-26-19) The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiary's Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card transition period and after for certain business areas that will continue to use the HICN as part of their processes. Additional documentation for the RO to use in making a determination of noncompliance includes: • Name, address, Medicare beneficiary identifier, and dates of stay of any involved Medicare beneficiary known to have been furnished covered services by the provider; • Where the services in question were furnished in a SNF, information relating to the beneficiary’s prior qualifying hospital stay, including if appropriate, copies of the Medicare billing submitted for the period of hospitalization; • Copies of any bills, receipts, letters, that were received by the beneficiary from the provider requesting payment, including, if available, a description of the services furnished to assure that payment was requested for “covered services”; • Copies of any checks, money orders, receipts, etc., which show payment to the provider by the beneficiary; • Copies of any materials available which would show the payment conditions under which the beneficiary was furnished services, e.g., a contract of admittance; • Copies of all pertinent “request for payment” forms that may have been filed by the provider for services furnished to the beneficiary during the period in question. If requests for payment were filed and the provider received program payment, the RO secures a written statement from the intermediary that shows that program payment (and the amount) was made to the provider on behalf of the beneficiary. For those cases where program payment has not been made (including cases where the provider has not filed a request for payment), secure a written opinion from the intermediary (based on available medical records and/or billings) as to the probability for making program payment; • Copies of any requests by the beneficiary for the return of amounts paid to the provider for covered services, including any reply by the provider; and • Authorization for the United States to act on behalf of the beneficiary. If the beneficiary has instituted any legal action to recover amounts paid to the provider, the RO does not secure the authorization. Use the following format: Authorization I hereby request that the United States act on my behalf to recover from (name of provider) amounts which I paid to said (hospital, nursing home, etc.) for services covered under title XVIII of the Social Security Act, popularly known as Medicare. I hereby affirm that I am an eligible Medicare beneficiary and that as such I was a patient at said (hospital, etc.) from to ____(insert dates) and that I paid said (hospital, etc.) $ (insert amount paid) for services rendered during this period. Signed Medicare beneficiary identifier All of the information listed above should be obtained by the Division of Medicare as part of its responsibility in monitoring Medicare fiscal intermediaries. 3028C - Additional Documentation - Failure to File Cost Reports (Rev. 1, 05-21-04) The RO provides a listing of all pertinent health insurance checks, including check number, date, amount, disposition, drawn payable to the provider by the intermediary. (This information is to be shown under an intermediary letterhead and signed by a responsible person.) The RO includes a breakdown to show separately the period (“from to ”) that related to these payments, including any offset against payments which may be due the provider, the total payment for the period involved, and the method of payment, e.g., periodic interim payments. The RO reviews the data and material received from the intermediary and the additional documentation listed here and in subsection A, above, to avoid a duplication of development and documentation. If the case file shows that the provider has also failed to make satisfactory refund of overpayments, see subsection D. 3028D - Additional Documentation - Failure to Make Satisfactory Overpayment Arrangements (Rev. 1, 05-21-04) The RO reviews the data and material received from the intermediary and the documentation listed in subsection A to avoid a duplication of development and documentation. If the case file shows that the provider has also failed to file a cost report, see subsection C. Section 1866(b)(2)(A) of the Act provides the authority to terminate the agreement of a provider that has failed to refund a substantial overpayment. For this purpose, when a provider has failed to make satisfactory arrangements for repayment, the sum of $1,000 or more may be viewed as a substantial overpayment. However, when considering termination of an agreement, the RO takes into consideration the full circumstances of the particular case. 3028E - Additional Documentation - Admission Policies and Practices (Rev. 1, 05-21-04) As provided in 42 CFR 489.53(a)(2), participation of a provider that voluntarily files an agreement to participate in the Medicare program, contemplates that the provider accepts beneficiaries for care and treatment. If a participating provider has any restrictions on the types of services it makes available and/or the type of health conditions that it accepts, or has any other criteria relating to the acceptance of persons for care and treatment, it is expected that such restrictions or criteria, if made applicable to Medicare beneficiaries, are applied in the same manner to all other persons seeking care and treatment. A provider’s admission policies and practices that are inconsistent with the provider agreement objectives set forth in this paragraph may be the basis for termination of participation by the Secretary pursuant to §1866(b)(2)(A) of the Act and 42 CFR 489.53(a)(2). The amount of documentation for a provider’s failure to meet the above requirements is dictated by the circumstances of the particular case. Thus, the RO attempts to secure from all available sources (e.g., beneficiaries, providers, and intermediaries) any information that would be useful in making the determination.