Provider/Supplier Contacts by the UPIC

4.7.1.1 – Provider/Supplier Contacts by the UPIC (Rev. 11032; Issued: 09-30-21; Effective: 10-12-21; Implementation: 11-10-21) This section applies to UPICs. A UPIC may determine that the resolution of an investigation does not warrant administrative action and that an educational meeting with the provider/supplier is more appropriate. The UPIC shall inform the provider/supplier of the questionable or improper practices, the correct procedure to be followed, and that continuation of the improper practice may result in administrative actions. The UPIC shall document contacts and/or warnings with written reports and correspondence to the provider/supplier and place them in the investigation file in the UCM. If the provider/supplier continues aberrant billing practices, the UPIC shall initiate the appropriate administrative actions. If the UPIC meets with a provider/supplier, the UPIC shall prepare a detailed report for the investigation file in the UCM. The report shall include the information in A, B, and C below: A. Background of Provider/Supplier (Specialty) The UPIC shall include a list of all enterprises in which the subject had affiliations, the states where the provider/supplier is licensed, all past complaints, and all prior educational contacts/notices. B. Total Medicare Earnings The UPIC shall include a report of the subject provider’s/supplier’s total Medicare earnings for the past 12 months. The report shall include the following: • Earnings for the procedures or services in question; • Frequency of billing for these procedures/services; and • Total number of claims submitted for these procedures/services. C. Extent of Review Performed The UPIC shall include in the detailed report, to be placed in the investigative file, the number and type of reviews performed, as well as the specific information outlined below: • A report of the review process, including methodologies utilized, reason for the review, and findings; • Any administrative actions implemented (e.g., overpayments identified); and • Recommendation(s). D. Report of Meeting The UPIC shall include information pertaining to the meeting(s) conducted with the provider/supplier. This report shall include the following: • Minutes from the meeting describing the problems and/or aberrancies discussed with the provider/supplier and the education provided to the provider/supplier to correct those problems based on the UPIC’s MR; and • Copies of educational materials given to the provider/supplier before, during, or subsequent to the meeting. E. Written Correspondence Regarding Non-compliance Per the abuse of billing authority under 42 C.F.R. § 424.535(a)(8)(ii) for a pattern or practice of submitting claims that do not meet Medicare requirements and in an effort to fully inform providers of the potential administrative actions that may be imposed based on continued violations of Medicare policy, the below statement should be included in all post payment correspondence that include an error rate, and if applicable, other communications that identify non-compliant billings and inform the provider/supplier of their non-compliance with Medicare requirements. In addition, we remind you that our regulation at 42 CFR § 424.535 authorizes us to revoke Medicare billing privileges under certain conditions. In particular, we note that per 42 CFR § 424.535(a)(8)(ii), CMS has the authority to revoke a currently enrolled provider’s or supplier’s Medicare billing privileges if CMS determines that the provider or supplier has a pattern or practice of submitting claims that fail to meet Medicare requirements. \