(a) An MCO is required by §353.502 of this title
(relating to Managed Care Organization's Plans and Responsibilities
in Preventing and Reducing Waste, Abuse, and Fraud) and §370.501
of this title (relating to Purpose) to establish and maintain an SIU
to investigate allegations of waste, abuse, or fraud for all services
in the MCO plan. If an MCO suspects possible waste, abuse, or fraud,
the MCO must conduct a preliminary investigation in accordance with
criteria in §353.502 and §370.501 of this title. If the
preliminary investigation confirms waste, abuse, or fraud, the MCO
must refer the matter to the OIG in accordance with §353.505
of this title (relating to Recovery of Funds).
(b) For a potential overpayment amount less than $100,000,
the MCO pursues recovery of the overpayment, and remits one-half of
the recovered amount in accordance with §353.505 of this title
(relating to Recovery of Funds).
(c) For MCO referrals to the OIG where the potential
overpayment amount exceeds $100,000, the OIG accepts the referral
and conducts a preliminary investigation.
(1) The OIG evaluates the allegation(s) and evidence
from the MCO-SIU for intentional deception, repeat billing pattern,
or other indicators of questionable practices.
(2) The OIG determines within 30 business days whether
to take additional investigative action, and notifies the referring
MCO of the decision.
(d) If the preliminary investigation determines a full
investigation is warranted, the OIG assesses the provider's billing
activity in fee-for-service Medicaid and other MCOs in which the provider
is credentialed.
|