Quality of Care Issues and Potential Fraud Issues

1.3.6 - Quality of Care Issues and Potential Fraud Issues (Rev. 12772; Issued: 08-09-24; Effective: 09-20-24; Implementation: 09-20-24) Potential quality of care issues are not the responsibility of the MAC, CERT or Recovery Auditor, UPIC, and SMRC but they are the responsibility of the QIO, State licensing/survey and certification agency, or other appropriate entity in the service area. MACs, CERT, Recovery Auditor, UPICs and SMRC shall refer quality of care issues to the QIO, State licensing/survey and certification agency, or other appropriate entity in the service area. See chapter 3, section 3.1, for a discussion of how contractors should handle situations where providers are non-compliant with Medicare conditions of participation. Contractors shall analyze provider compliance with Medicare coverage and coding rules and take appropriate corrective action when providers are found to be non-compliant. For repeated infractions, or infractions showing potential fraud or pattern of abuse, more severe administrative action shall be initiated. At any time, evidence of fraud shall result in referral to the UPICs for development. See chapter 4, section 4.9.4.2 for a discussion on program integrity interaction with QIOs.