Evaluation of Postpayment Review Effectiveness

3.7.3.3 - Evaluation of Postpayment Review Effectiveness (Rev. 10365; Issued: 10-02-20; Effective: 08-27-20; Implementation: 08-27-20) This section applies to MACs. The MACs shall determine if any other corrective actions are necessary such as: • Uncovering potential fraud in the course of MR postpayment review activities. The MR unit shall refer these cases to the UPIC. If it is believed that the overpayment resulted from potential fraud, a refund may not be requested from the provider until the potential fraud issue is resolved. • Initiating provider or supplier specific edits to focus prepayment view on the problem provider or supplier or group of providers or suppliers, if appropriate ; • Working with the CMS Central Office Division of Benefit Integrity Management Operations (DBIMO) Fraud and Abuse Suspensions and Sanctions (FASS) Team to suspend payment to the provider or group of providers; • Referring provider certification issues to the State survey agency through CMS staff; • Referring quality issues involving inpatient hospital services to the RO and QIO; and • Coordinating with the QIO and MAC on interrelated billing problems The MACs periodically perform a follow-up analysis of the provider(s) or supplier(s) for as long as necessary to determine if further corrective actions are required. In some cases, it may be feasible and timely to perform the follow-up analysis of the provider or supplier after the three (3) month time period. The MACs shall continue to monitor the provider(s) or supplier(s) until there is a referral to the UPICs for potential fraud, evidence that the utilization or billing problem is corrected, or data analysis indicating resources would be better utilized elsewhere.