Investigations

4.7 – Investigations (Rev. 11358; Issued: 04-21-2022; Effective: 05-23-2022; Implementation: 05-23- 2022) This section applies to UPICs. An investigation is the expanded analysis performed on leads once such lead is vetted and approved by CMS to be opened as an investigation. The UPIC shall focus its investigation in an effort to establish the facts and the magnitude of the alleged fraud, waste, or abuse and take any appropriate action to protect Medicare Trust Fund dollars within 210 calendar days, unless otherwise specified by CMS. For any investigative activities that require preapproval by CMS (i.e., activities referenced in Section 4.7.1.2), the UPIC shall submit those requests to CMS for approval with a copy to its COR and BFLs for approval when initiating those actions. Prioritization of the investigation workload is critical to ensure that the resources available are devoted primarily to high-priority investigations. The UPIC shall ensure that all investigations originating from an Accountable Care Organization (ACO) referral or involving ACOs, ACO participants or ACO providers/suppliers are provided a heightened level of priority and are promptly reviewed and investigated to ensure the appropriate administrative or other action(s) are taken in an expeditious manner. The UPIC shall maintain files on all investigations. The files shall be organized by provider or supplier and shall contain all pertinent documents including, but not limited to, the original referral or complaint, investigative findings, reports of telephone contacts, warning letters, documented discussions, documented results of any investigative activities, any data analysis or analytical work involving the potential subject or target of the investigation, and decision memoranda regarding final disposition of the investigation (refer to section 4.2.2.6.2 of this chapter for information concerning the retention of these documents). Under the terms of their contract, the UPICs shall investigate potential fraud, waste, or abuse on the part of providers, suppliers, and other entities that receive reimbursement under the Medicare program for services rendered to beneficiaries. The UPICs shall refer potential fraud cases to LE, as appropriate, and provide support for these cases. In addition, the UPICs may provide data and other information related to potential fraud cases initiated by LE when the cases involve entities or individuals that receive reimbursement under the Medicare program for services rendered to beneficiaries. For investigations that the providers/suppliers are subject to prior authorization by the MAC, the UPIC may request the MAC to release the prior authorization requirement prior to pursuing the investigation further. For those investigations that are national in scope, CMS will designate a lead UPIC, if appropriate, to facilitate activities across the zones.