Referral Process to CMS

4.11.6.1 - Referral Process to CMS (Rev. 11962; Issued: 04-21-23; Effective: 05-22-23; Implementation: 05-22-23) Compliance is promoted through both administrative and formal legal actions. Administrative compliance action shall first be attempted by MACs through education and warning letters that request the provider to comply with Medicare’s rules and regulations. If the provider fails to take corrective action and continues to remain non- compliant, the MAC shall make a referral to the UPIC who shall forward it to the BFL, with a copy to the COR. It is important for MACs to promote program compliance in their respective jurisdictions. The MACs shall ensure that all materials presented to providers through education, published bulletins, or written communication are clear and concise and accurately represent the facts of compliance versus non-compliance. Providers shall also be allowed the opportunity to present additional facts that may represent mitigating circumstances. UPICs shall consider this information in an objective manner before proceeding with a CMP referral to CMS. When a UPIC elects to make a CMP referral to CMS, the initial referral package shall consist of a brief overview of the case; supportive documentation is not required at such time. The initial referral package shall consist of: 1. Identification of the provider, including the provider’s name, address, date of birth, Social Security number, Medicare identification number(s), and medical specialty. If the provider is an entity, include the names of its applicable owners, officers, and directors. 2. Identification of the CMP authorities to be considered (use the authorities identified in PIM Chapter 4, §4.11.5). 3. Identification of any applicable Medicare manual provisions. 4. A brief description of how the violations identified above were discovered, and the volume of violations identified. 5. Total overpayments due the program or the beneficiary(ies), respectively. 6. A brief chronological listing of events depicting communication (oral and written) between the MAC and the provider. 7. A brief chronological listing of bulletins addressing the non-compliant area (starting with the bulletin released immediately prior to the first incident of non- compliance by the provider). 8. Any additional information that may be of value to support the referral. 9. The name and phone number of contacts at the UPIC. Upon receipt of the above information, CMS staff will review the materials and may conduct follow-up discussions with the UPIC regarding the referral. Typically, within 90 days of receipt of the referral, CMS will notify the UPIC of its decision to accept or decline the referral. If CMS declines the referral, the UPIC shall communicate this to the MAC to continue in their efforts to educate and promote compliance by the provider. The UPIC shall also consider other (less severe) administrative remedies, which, at a minimum, may include revocation of assignment privileges, establishing prepayment or postpayment medical reviews, and referral of situations to state licensing boards or medical/professional societies, where applicable. In all situations where inappropriate Medicare payments have been identified, MACs shall initiate the appropriate steps for recovery. If CMS accepts the referral, the UPIC shall provide any supportive documentation that may be requested, and be able to clarify any issues regarding the data in the case file or UPIC and MAC processes.