Referrals to the UPIC

4.3.2.4 - Referrals to the UPIC (Rev. 12772; Issued: 08-09-24; Effective: 09-20-24; Implementation: 09-20-24) MACs that refer a complaint to the UPIC shall notify the UPIC via e-mail that a complaint is being referred as potentially fraudulent. The MAC shall develop a referral package (see below for what should be included in the referral package) for all complaints being referred to the UPIC and shall send the complaint via a secure method such as e-mail or mail directly to the UPIC. Complaints shall be forwarded to the UPIC for further review under the circumstances listed below (this is not an exhaustive list): • Claims may have been altered • Claims have been up-coded to obtain a higher reimbursement amount and appear to be fraudulent or abusive; • Documentation appears to indicate that the provider/supplier has attempted to obtain duplicate reimbursement (e.g., billing both Medicare and the beneficiary for the same service or billing both Medicare and another insurer in an attempt to be paid twice). An example of an attempt to obtain duplicate reimbursement might be that a provider/supplier has submitted a claim to Medicare, and then in two (2) business days resubmits the same claim in an attempt to bypass the duplicate edits and gain double payment. This apparent double-billing does not include routine assignment violations. The MAC shall attempt to resolve all routine assignment violations. However, referral from the MAC to the UPIC shall be made in instances where the provider/supplier has repeatedly committed assignment violations, indicating a potential pattern; • Potential misrepresentation with respect to the nature of the services rendered, charges for the services rendered, identity of the person receiving the services, identity of persons or doctor providing the services, dates of the services, etc.; • Alleged submissions of claims for non-covered services are misrepresented as covered services, excluding demand bills and those with Advanced Beneficiary Notices (ABNs); • Claims involving potential collusion between a provider/supplier and a beneficiary resulting in higher costs or charges to the Medicare program; • Alleged use of another person’s Medicare number to obtain medical care; • Alleged alteration of claim history records to generate inappropriate payments; • Alleged use of the adjustment payment process to generate inappropriate payments; or • Any other instance that is likely to indicate a potential fraud, waste, and abuse situation. Note: Since this is not an all-inclusive list, the UPIC has the right to request additional information in the resolution of the complaint referral or the subsequent development of a related case (e.g., provider/supplier enrollment information). When the above situations occur requiring that the complaint be referred to the UPIC for review, the MAC shall prepare a referral package that includes, at a minimum, the following: • Provider/supplier name, NPI, provider/supplier number, and address. • Type of provider/supplier involved in the allegation and the perpetrator, if an employee of the provider/supplier. • Type of service involved in the allegation. • Place of service. • Nature of the allegation(s). • Timeframe of the allegation(s). • Narration of the steps taken and results found during the MAC’s screening process (discussion of beneficiary contact, if applicable, information determined from reviewing internal data, etc.). • Date of service, procedure code(s). • Beneficiary name, beneficiary HICN, telephone number. • Name and telephone number of the MAC employee who received the complaint. If a provider/supplier is found to be previously referred to the UPIC and on an active Payment Suspension, it is important to appropriately close the complaint in the applicable system(s) (i.e., Next Generation Desktop (NGD), MAC system(s), etc.) and ensure the information is communicated to the UPIC. The following actions shall occur in cases where a complaint is received for a provider/supplier previously referred to the UPIC and on an active Payment Suspension: • Continue to report new claims identified in subsequent complaints to the UPIC; • Close complaints in the applicable system(s) (i.e., NGD, MAC system(s), etc.; however, do not cancel them) with a note that references this PIM section; • Do not send any notification or communication to the beneficiary or provider; • Do not conduct any additional research (calls to the provider and/or beneficiary, claims history reviews, other records or complaints reviews, additional documentation requests or, medical record requests); • Refer the complaint to the applicable UPIC as through the process outlined in your JOA. It is very important that UPICs are promptly notified of these subsequent complaints. Each MAC should work with its respective UPIC(s) to identify what additional details are needed and how best to communicate these complaints since they will not be communicated via formal referral. At a minimum, complaints that fall under this category should be communicated monthly. NOTE: Since this is not an all-inclusive list, the UPIC has the right to request additional information in the resolution of the complaint referral or the subsequent development of a related case (e.g., provider/supplier enrollment information). The MAC shall maintain a copy of all referral packages.