Definition of a Complaint

4.3.1 - Definition of a Complaint (Rev. 11032; Issued: 09-30-21; Effective: 10-12-21; Implementation: 11-10-21) This section applies to UPICs and MACs. A complaint is a statement, oral or written, alleging that a provider, supplier, or beneficiary billed for and/or received a Medicare reimbursement or benefit to which he or she is not entitled under current Medicare law, regulations, or policy. Included are allegations of misrepresentation and violations of Medicare requirements applicable to persons or entities that bill for covered items and services. Examples of complaints include (this is not an exhaustive list): • Allegations that items or services were not received; • Allegations that items or services were not furnished as shown on the Explanation of Medicare Benefits (EOMB), Notice of Utilization (NOU), or Medicare Summary Notice (MSN), or that the services were not performed by the provider/supplier shown; • Allegations that a provider/supplier is billing Medicare for a different item or service than was furnished; • Allegations that a provider or supplier has billed both the beneficiary and Medicare for the same item or service; • Allegations regarding waiver of co-payments or deductibles; • Allegations that a supplier or provider has misrepresented itself as having an affiliation with an agency or department of the state, local, or federal government, whether expressed or implied; and • Allegations or inquiries from a beneficiary concerning payment for an item or service that, in his/her opinion far exceeds reasonable payment for the item or service that the beneficiary received (e.g., the supplier or physician has “upcoded” to receive higher payment). The following are not examples of a fraud complaint (this is not an exhaustive list): • Complaints or inquiries regarding Medicare coverage policy; • Complaints regarding the appeals process; • Complaints over the status of a claim; • Requests for an appeal or reconsideration; or • Complaints concerning providers or suppliers (other than those complaints meeting the criteria established above) that are general in nature and are policy- or program-oriented. Complaints alleging malpractice or poor quality of care may or may not involve a fraudulent situation. These complaints shall be reviewed and determined on a case-by- case basis. The UPIC shall refer complaints alleging poor quality of care to the Medicare/Medicaid survey and certification agencies and the QIOs within two (2) business days. The UPIC shall forward any medical records to the QIO upon receipt from the provider, when appropriate. Any complaints involving allegations of fraud shall be screened to determine if further investigation by the UPIC is necessary.