January 2003

CMS gives marching orders on beneficiary complaints

The Centers for Medicare & Medicaid Services still is as gung-ho as ever when it comes to responding to allegations of fraud and abuse. That’s the message physicians and other providers can take away from a recent program memorandum in which CMS gives strict instructions to Affiliated Contractors (AC) and Program Safeguard Contractors (PSC) about “complaint screening.”

“A fraud or abuse complaint is a statement, oral or written, alleging that a provider, supplier or beneficiary received a Medicare benefit of monetary value, directly or indirectly, overtly or covertly, in cash or in kind, to which he or she is not entitled under current Medicare law, regulations, or policy,” CMS notes in the memo.

When an AC receives a complaint, its first duty is to determine if the allegation is legit or if it’s simply a misunderstanding or billing error. If the AC decides the problem doesn’t stem from a misunderstanding and could actually be fraud, it must document the reasons for that decision. Then, the AC must pass the information on to a PSC for further investigation within 30 days.

Once the PSC receives the complaint, it must “further develop the complaint, order medical records, resolve the complaint or make referrals as needed to appropriate law enforcement entities or other outside entities.”

If after taking these steps, the PSC decides the complaint isn’t in fact a fraud or abuse issue, it gets bounced right back to the AC “for further action.”

Source: Medical Newswire

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