Conducting Investigations

4.7.1 – Conducting Investigations (Rev. 11962; Issued: 04-21-23; Effective: 05-22-23; Implementation: 05-22-23) The UPIC shall, unless otherwise advised by CMS, use one or more of the following investigative methods (this is not an exhaustive list): • Screening activities as referenced in Section 4.5; • Contact with the subject provider or ordering/referring providers via telephone or on-site visit; • Medical record requests and reviews (as defined in PIM, chapter 3); • Prepayment medical reviews associated with a limited claim count (i.e., 25- 50 claims) or targeted review (i.e., specific CPT codes) (as defined in PIM, chapter 3); • Implementation of auto-denial edits; and • Recommendation of other administrative actions (as defined in PIM chapters 3, 8, and 10) to CMS. These items will include any administrative actions identified below to be discussed during the case coordination meetings. Additionally, the UPICs shall coordinate with LE partners prior to making contact with any provider/supplier, when it knows there is or was a LE case on the provider/supplier. The UPIC shall review the Unified Case Management (UCM) system prior to contacting any provider/supplier to verify the following: • There are no current or prior requests for information from LE; • There are no other current or prior coordination activities with LE concerning the provider; and • The CMS vetting response indicates there is no current LE activity associated with the provider/supplier. If the UPIC identifies prior LE activity within the past 24 months, the UPIC shall communicate with the LE contact person identified in the UCM to determine if making contact with a provider/supplier will impact its case. If the UPIC is not able to identify the LE contact person in UCM, the UPIC shall consult with its BFL for further guidance. Once the UPIC contacts LE, it shall document the results of the conversation, including the date, time, name of the individual, and the specific LE agency in UCM prior to contacting the provider/supplier. If the UPIC has attempted to contact LE on multiple occasions within five (5) business days, but does not receive a response, the UPIC shall notify its BFL, with a copy to the COR, for CMS escalation to the appropriate LE contacts. For any investigative activities that require approval by CMS (i.e., Payment Suspension or revocation/deactivation requests), the UPIC shall submit those requests through its current processes (i.e., via UCM) and coordinate subsequent actions with the appropriate points of contact within CMS. After reviewing the provider's/supplier’s background, specialty, and profile, the UPIC decides whether the situation involves potential fraud, waste, or abuse, or may be more accurately categorized as a billing error. For example, records might indicate that a physician has billed, in some instances, both Medicare and the beneficiary for the same service. Upon review, the UPIC may determine that, rather than attempting to be paid twice for the same service, the physician made an error in his/her billing methodology. Therefore, this error would be considered a determination of incorrect billing, rather than potential fraud, waste, or abuse involving intentional duplicate billing. If the UPIC determines that an overpayment exists solely on data analysis, the UPIC shall obtain BFL approval prior to initiating the overpayment.