Referral to State Agencies or Other Organizations

4.9.4.1 - Referral to State Agencies or Other Organizations (Rev. 11962; Issued: 04-21-23; Effective: 05-22-23; Implementation: 05-22-23) The UPIC shall refer instances of apparent unethical or improper practices or unprofessional conduct to state licensing authorities, medical boards, the QIO, or professional societies for review and possible disciplinary action. Additionally, referrals should be made to the Medicare survey and certification agency which exist in each state, typically within the state’s Department of Health. The survey agency has a contract with CMS to survey and certify institutional providers, indicating whether they meet or do not meet applicable Medicare health and safety requirements, called “conditions of participation.” Providers not meeting these requirements are subject to a variety of adverse actions, including bans on new admissions to termination of their provider agreements. These administrative sanctions are imposed by the Regional Office, typically after an onsite survey by the survey agency. The UPIC’s and the MAC’s MR staffs shall confer before such referrals, to avoid duplicate referrals. The UPIC shall gather available information and leave any further investigation, review, and disciplinary action to the appropriate professional society or State board. Consultation and agreement between the UPIC’s and the MAC’s MR staffs shall precede any referral to these agencies. The UPIC shall notify its BFL, with a copy to the COR, of these referrals.