CMS contractors such as Unified Program Integrity Contractors (UPICs) are tasked with ensuring that Medicare pays the right amount for covered services by legitimate providers. Specifically, a UPIC’s main goal is to identify cases of suspected fraud, waste and abuse, and additionally, to take immediate administrative action to protect federal program funds. Within its administrative action toolkit, apart from the common pre- or post-payment reviews and payment suspensions, UPICs have the ability to refer cases of potential fraud to law enforcement agencies.
In most instances, referrals originate from documented patterns of improper billing, the submission of improper claims with suspected knowledge of their falsity, or the submission of improper claims with reckless disregard or deliberate ignorance of their truth or falsity. To put this into perspective let’s translate this into situations in the DME industry, for example. Referral would likely occur in the situation of suppliers submitting claims for items not provided, suppliers continuing to submit claims for rental items that are no longer determined to be medically necessary, suppliers taking or accepting kickbacks or bribes, and suppliers falsifying medical documentation (e.g. certificates of medical necessity) in support of a claim.
The main recipients of referrals are the U.S. Department of Health and Human Services Office of Inspector General (OIG) and the Federal Bureau of Investigation (FBI). If referred by a UPIC, the OIG has 60 days to either accept or decline a referral. If to other agencies such as the FBI, the agencies have 45 days to accept or decline. If declined, the UPIC may continue to monitor and make additional referrals in the future. On the other hand, if accepted, a UPIC will work in conjunction with law enforcement to assist in establishing evidence of any statutory violations.
What does a referral mean in the big picture? It could lead to surprise interviews by agents and/or the service of civil investigative demands or grand jury subpoenas. If contacted by law enforcement, seeking experienced legal representation to help you navigate your legal options and defend against any allegations of fraudulent activity is critical.