Identification of Potential Exclusion Cases

4.10.2.2 - Identification of Potential Exclusion Cases (Rev. 11032; Issued: 09-30-21; Effective: 10-12-21; Implementation: 11-10-21) The UPIC shall review and evaluate abuse cases to determine if they warrant exclusion action. Examples of abuse cases suitable for exclusion include, but are not limited to: • Providers who have a pattern of adverse QIO or MAC findings; • Providers whose claims must be reviewed continually and are subsequently denied because of repeated instances of overutilization; • Providers who have been the subject of previous cases that were not accepted for prosecution because of the low dollar value; • Providers who furnish or cause to be furnished items or services that are substantially in excess of the beneficiary’s needs or are of a quality that does not meet professionally recognized standards of health care (whether or not eligible for benefits under Medicare, Medicaid, title V or title XX); • Providers who are the subject of prepayment review for an extended period of time (longer than 6 months) who have not corrected their pattern of practice after receiving educational/warning letters; • Providers who have been convicted of a program related offense (§1128(a) of the Social Security Act); or • Providers who have been convicted of a non-program related offense (e.g., a conviction related to neglect or abuse of a beneficiary, or related to a controlled substance) (§1128(a) of the Social Security Act). Also, §1833(a)(1)(D) of the Act provides that payment for clinical diagnostic laboratory tests is made on the basis of the lower of the fee schedule or the amount of charges billed for such tests. Laboratories are subject to exclusion from the Medicare program under §1128(b)(6)(A) of the Act where the charges made to Medicare are substantially in excess of their customary charges to other clients. This is true regardless of the fact that the fee schedule exceeds such customary charges. Generally, to be considered for exclusion due to abuse, the practices have to consist of a clear pattern that the provider/supplier refuses or fails to remedy in spite of efforts on the part of the UPIC, SMRC, MAC, or QIO groups. An exclusion recommendation is implemented only where efforts to get the provider/supplier to change the pattern of practice are unsuccessful. The educational or persuasive efforts are not necessary or desirable when the issues involve life-threatening or harmful care or practice. If a case involves the furnishing of items or services in excess of the needs of the individual or of a quality that does not meet professionally recognized standards of health care, the UPIC shall make every effort to obtain reports confirming the medical determination of its MR from one or more of the following: • The QIO for the area served by the provider/supplier; • State or local licensing or certification authorities; • QIO committees; • State or local professional societies; or • Other sources deemed appropriate.