Referrals

4.9 - Referrals (Rev. 11032; Issued: 09-30-21; Effective: 10-12-21; Implementation: 11-10-21) The UPIC shall refer investigations to law enforcement when it has substantiated allegations of fraud including, but not limited to, documented allegations that a provider, beneficiary, supplier, or other subject: (a) engaged in a pattern of improper billing, (b) submitted improper claims with suspected knowledge of their falsity, or (c) submitted improper claims with reckless disregard or deliberate ignorance of their truth or falsity. Prior to making such referrals, the UPIC shall follow the direction as outlined in § 4.9.2 Referral of Cases to the OIG/OI, unless otherwise instructed by CMS.