Organizational Requirements

4.2.2.3 – Organizational Requirements (Rev. 11962; Issued: 04-21-23; Effective: 05-22-23; Implementation: 05-22-23) This section applies to UPICs and MACs, as indicated. UPIC program integrity (PI) managers shall have sufficient authority to guide PI activities and establish, control, evaluate, and revise fraud-detection procedures to ensure their compliance with Medicare requirements. The UPIC shall follow the requirements in its UPIC SOW for prioritizing leads. UPIC PI managers shall prioritize work coming into the UPIC to ensure that investigations with the greatest program impact and/or urgency are given the highest priority. The UPIC shall prioritize all work on an ongoing basis as new work is received. Allegations having the greatest program impact and priority would include investigations cases involving, but not limited to: • Patient abuse or harm • Multi-state fraud • High dollar amounts of potential overpayment or potential for other admin actions, e.g. payment suspensions and revocations • Likelihood of an increase in the amount of fraud or enlargement of a pattern • LE requests for assistance that involve responding to court-imposed deadlines • LE requests for assistance in ongoing investigations that involve national interagency (HHS-DOJ) initiatives or projects. • Note: The UPIC and MAC shall give high priority to fraud, waste, or abuse complaints made by Medicare supplemental insurers. If a referral by a Medigap insurer includes investigatory findings indicating fraud stemming from site reviews, beneficiary interviews, and/or medical record reviews, the UPIC shall 1) conduct an immediate data run to determine possible Medicare losses, and 2) refer the case to the OIG.