Contents of Sanction Recommendation

4.10.2.3 - Contents of Sanction Recommendation (Rev. 11032; Issued: 09-30-21; Effective: 10-12-21; Implementation: 11-10-21) The UPIC shall include in the sanction recommendation (to the extent appropriate) the following information: • Identification of the subject, including the subject's name, address, date of birth, social security number, and a brief description of the subject's special field of medicine. If the subject is an institution or corporation, include a brief description of the type of services it provides and the names of its officers and directors. • A brief description of how the violation was discovered. • A description of the subject's fraudulent or abusive practices and the type of health service(s) involved. • A case-by-case written evaluation of the care provided, prepared by the UPIC’s, or MAC’s MR staff, which includes the patient's medical records. This evaluation shall cite what care was provided and why such care was unnecessary and/or of poor quality. (The reviewer may want to consult with someone from their RO CCSQ.) Medicare reimbursement rules shall not be the basis for a determination that the care was not medically necessary. The reviewer shall identify the specific date, place, circumstance, and any other relevant information. If possible, the reviewer should review the medical records of the care provided to the patient before and after the care being questioned. NOTE: A minimum of 10 examples shall be submitted in support of a sanction recommendation under §1128(b)(6)(B). In addition, none of the services being used to support the sanction recommendations shall be over 2 years old. • Documentation supporting the case referral, e.g., records reviewed, copies of any letters or reports of contact showing efforts to educate the provider, profiles of the provider who is being recommended for sanction, and relevant information provided by other program administrative entities. • Copies of written correspondence and written summaries of the meetings held with the provider regarding the violation. • Copies of all notices to the party. • Information on the amount billed and paid to the provider for the 2 years prior to the referral. • Data on program monies on an assigned/non-assigned basis for the last 2 years, if available. • Any additional information that may be of value in supporting the proposal to exclude or that would support the action in the event of a hearing. NOTE: All documents and medical records should be legible.