Referral of Cases to the MAC

4.9.4.3 – Referral of Cases to the MAC (Rev. 11032; Issued: 09-30-21; Effective: 10-12-21; Implementation: 11-10-21) There are certain instances when the UPIC may refer cases to the MAC for review and additional education. At any time during the course of a review of a provider, the UPIC may determine that referral to the MAC is appropriate. Under certain circumstances, CMS may direct the UPIC to initiate a referral to the MAC at any time if deemed appropriate. A. Situations When a Referral to the MAC is Appropriate The following are examples of when it may be appropriate for the UPIC to submit a referral to the MAC: • During lead screening, the UPIC determines that there is not a potential fraud, waste, or abuse issue (e.g. MR, enrollment, claims processing). • During lead screening, the UPIC determines that the risk for fraud, waste, or abuse is extremely low. Such a determination could be made based upon a low total amount of dollars at risk, information that the erroneous billing was unintentional or without a significant pattern. • During the investigation, the only available outcome deemed appropriate by the UPIC at the time is the identification of an overpayment and no referral to law enforcement or other administrative actions are contemplated (i.e. revocation, payment suspension, etc.). The UPIC shall complete their review, calculate the overpayment, and refer the matter to the MAC for issuance of the overpayment and for potential education and/or MAC medical review If the UPIC refers a provider/supplier to the MAC, but subsequently receives additional information of potential fraud, waste, and/or abuse that warrants further UPIC review, the UPIC shall inform the MAC that they are re-opening the investigation of the provider/supplier. B. Situations When a Referral to the MAC is Not Appropriate There are certain instances when the UPIC may determine that it is not appropriate to refer cases to the MAC for review. During the investigation, the UPIC may determine that the provider has been previously educated on the same issue(s) and there is a potential for the UPIC to pursue other administrative actions and/or referral to law enforcement. In those instances, the UPIC shall continue to monitor for fraud, waste, and/or abuse.