Non-DME National Payment Suspensions (MACs and UPICs)

8.3.3.2 – Non-DME National Payment Suspensions (MACs and UPICs) (Rev. 12515; Issued:02-22-24; Effective: 03-25-24; Implementation:03-25-24) For national payment suspensions involving national providers (such as chain hospitals, chain Skilled Nursing Facilities, franchised clinics, laboratories, etc.) that are enrolled in multiple jurisdictions, the following may be applicable for MACs and UPICs: • When CMS suspends payments to a national provider, all payments to the national provider are suspended in all jurisdictions if they share the same Tax Identification Number. The information (whether based on fraud or non-fraud) that payments should be suspended in one jurisdiction is sufficient reason for payment suspension decisions to apply to the other locations. • The UPIC that requests the national payment suspension to CPI shall become the “Lead” UPIC for the payment suspension. The Lead UPIC is responsible for informing the other UPICs (non-lead UPICs) of the payment suspension being initiated and for the coordination regarding the payment suspension activities. CMS suggests that monthly contractor calls be held to communicate the current activities by each of the contractors. • The Lead UPIC is responsible for coordinating and reporting to its BFL, with a copy to the COR, whether the non-lead UPICs are compliant with the payment suspension timeframe and activities. • All non-lead UPICs are responsible for determining an overpayment(s) for its jurisdiction. Non-lead UPICs shall take into account the findings of the Lead UPIC and take appropriate measures (prepayment review, etc.) to protect and safeguard Medicare Trust Fund dollars from being inappropriately paid. For UPIC-initiated non-DME national payment suspensions: • Each UPIC shall be responsible for ensuring that the payment suspension edit has been initiated in its respective MAC jurisdiction and has communicated this to the Lead UPIC. If non-lead UPIC determines that medical review would not be appropriate in their jurisdiction for subject provider, non-lead UPIC shall notify and request permission from their BFL to opt out of the medical review. • The Lead UPIC shall create both a CSE record to track the investigative activities and a PSP record to track the activities specific to the payment suspension in UCM. The lead UPIC shall check the “lead” checkbox. Non- lead UPICs shall not create a separate PSP and is responsible for timely updating the lead UPIC’s PSP with monthly suspended amounts within their jurisdictions, as well as adding any pertinent comments and/or documentation. Non-lead UPICs shall create a CSE and the appropriate administrative action records to track their activities.