(Medicare Claims Processing Manual)

The CMS and OIG have reached the following agreement as to the division of functional responsibilities with regard to the screening and investigation of alleged violations of 1882(d):   1. CMS, through its regional offices, is responsible for the preliminary screening of complaints and for providing information regarding the complaints to the appropriate State Insurance Department.   2. The OIG is responsible for the investigation of cases referred by the CMS RO and for coordinating investigatory activities with the State Ins urance Departments if requested and warranted. Further, OIG will provide any necessary liaison between State Insurance Departments and the U.S. Attorneys.  B.   CMS RO Responsibilities   Upon receipt of a complaint, the RO sends an informational copy of the  complaint and any supporting documentation to the Regional Office of the Inspector General. The Special Agents in Charge will serve as the OIG contact point for CMS referrals.   Additionally, the RO sends a copy of the original complaint and any supporting documentation to the appropriate State Insurance Department. This is to be accompanied by a request for information as to the status of any State investigation regarding the same agent or company or the specific case in question.   1. If the State indicates that it is currently investigating, or intends to investigate the agent or company, the RO provides any information which may be helpful to the State and advise the State of the existence of the Federal penalty provisions and the availability of investigatory advice and/or assistance from the Regional Office of the Inspector General.   If the facts also indicate that a Federal violation may exist, the RO should keep the file open and request that the State advise them as to the status and, eventual ly, the disposition of the case.   If the facts indicate a possible State violation but no Federal violation, the RO out the case after referring it to the appropriate State Insurance Department.   In either event, the RO should respond to the complainant that the case has been referred to the State Insurance Department for investigation. The RO sends a copy  of this response to the State, Regional OIG, and to the Medigap Operations Staff (MOS).   2. Where the State indicates that it does not plan to take action o n the case, or where no response is received from the State within a reasonable period of time, i.e., not more than 30 days, the RO should proceed to screen the case. This activity consists of:    Verifying the facts alleged in the complaint; and    Determinin g whether the facts appear to constitute prohibited activity.  3. Where preliminary screening indicates that a mistake of fact exists, or that the facts do not indicate a Federal violation, the RO should respond to the complainant and attempt to clarify the misunderstanding. The RO sends a copy of the RO response to the complainant to MOS, the Special Agent in Charge, and the appropriate State Insurance Department.   Verification of Facts -  The A/B MAC (A, B, HH) or DME MAC  logs in complaints as they are receiv ed and establishes appropriate procedures to ensure that follow -up action is taken on any request for additional information. Verification of facts may include interviewing the complainant (either by phone or in person, as appropriate) to:    Determine whether the facts, as originally reported, are accurate and precise;    Clarify statements that are confusing or contradictory as originally recorded.   Secure any missing or additional information; and   Determine whether any similar complaints or a dditional information may be derived from others (e.g., relatives or neighbors).   In interviewing the complainant and others, keep in mind the substantive facts that may lead to prosecution. The MAC uses the suggested format for referral to the Regional OI G as a checklist for the interview.  As far as possible, the RO should keep the complainant informed of the status of the action taken on the complaint.  So as to maintain a high level of cooperation; inform the complainant when he can expect to be contact ed again, who will contact him, etc.   It is important that the RO not  directly contact either the agent or the insurance company involved since this falls within the purview of investigation and is the function of the OIG.   Referral to the Regional Office of the Inspector General -  When the preliminary screening process reveals an indication that the Federal law has been violated, refer the case to the Regional OIG for additional development.  The OIG performs the necessary  investigation and coordinates wit h the appropriate U.S. Attorney for prosecution. At this point, CMS will cooperate with any request by the U.S. Attorney, State Insurance Department, and OIG to promote timely and successful prosecution.   If there should be any questions regarding this scr eening and referral activity, contact the Director, Medigap Operations Staff at the address below.  Centers for Medicare & Medicaid Services  Director, Medigap Operations Staff  7500 Security Blvd. Baltimore, Maryland 21244- 1850  110.2 - Preliminary Screenin g and Referral to Regional Office of the Inspector General  (Rev. 2906, Issued: 03- 14-14, Effective: 04 -14-14, Implementation 04- 14-14)  The Regional Office should perform preliminary screening activities, which may include interviewing the complainant in person or by phone (if appropriate), in order to reach a determination as to referral of the case for further investigation to the Special Agent in Charge, Office of Investigations, Regional Office of the Inspector General, HHS.  At the point where the RO believes that there exists an indication of the violation of one of the Federal penalty provisions, the RO should prepare a formal referral to the Regional OIG.  In cases where there is uncertainty as to whether the Federal law has been viol ated, the case should be referred notwithstanding the uncertainty. The referral should reflect the following information:   A. Type of violation, e.g., the complainant alleges a violation of 1882(d)(2);   B. Name, address, and telephone number of the complainant ; and   C. A narrative description of the facts, which should include:   1. All circumstances regarding the contact made by the subject with the beneficiary:   a.  Type of contact (phone, personal);   b.  Stated reason (if any) for selection of the beneficiary by the subject making the contact, e.g.:   i.   Beneficiary lives in a senior citizens community or complex;   ii.  The existence of another insurance policy with the same company; and    iii.  Referral by a third party.   2. Date, time, place, and dur ation of all contacts;  3. Words that were used to gain entry into the beneficiarys home, e.g., Im from Medicare, SSA, or other Federal Government agency;   4. Details of the subjects sales pitch or presentation:  a.  Was there a discussion of the existenc e of other health insurance policies currently held by the beneficiary?  b.  Did the agent know that his policy was duplicative of Medicare or a currently held policy?  c.  Amount of premium of policy that agent was trying to sell. Obtain a copy of the policy if possible;  d.  Existence of any hard sell or intimidation tactics on the part of the agent.   5.  Details of the Agents exit:  a.  Business card left by agent; and  b.  Follow-up calls by agent or others.  D.  Other Information:  1.  Name of contact person in the Regional Office;  2.  Copy of the original complaint; and  3.  Any other supporting documentation.  110.3 - CMS Regional Office Quarterly Report on Medicare Supplemental Health Insurance Penalty Provision Activity  (Rev. 2906, Issued: 03-14-14, Effective: 04-14-14, Implementation 04-14-14)   The ROs should submit to the Director, Medigap Operations Staff, a report summarizing activities with regard to the screening and referral of complaints falling under the penalty provisions of 1882(d). This report will be used to compile the Secretarys report to Congress as required by 1882(f)(2) . Under the terms of this paragraph, the Secretary must submit a report to Congress beginning July 1, 1982 (and at least every two years  thereafter) evaluating, among other things, the effectiveness of the criminal penalties.  The following information from the Regional Offices is necessary for that evaluation.  110.3.1 - Statistics  (Rev. 2906, Issued: 03- 14-14, Effective: 04-14-14, Implementation 04-14-14)   The number of complaints received broken down by the type of alleged violation, e.g., 1882(d)(2).  The origin of the complaints:   Complaint was made directly to RO;   Com plaint was referred by other Federal agency; State agency;    Complaint was referred by consumer group;   Other;    The number of interviews (contacts) held to validate the facts of the case;   The number referred (after screening) to the Regional Office of the Inspector General for investigation; and   The number of cases closed -out:  o For mistake or misunderstanding; o Referral to State for violations of State law; o Other.    The number of cases prosecuted and, for each, the name of the agent/company and disposition of the case; and   The number of cases currently pending.  110.3.2 - Narrative  (Rev. 2906, Issued: 03- 14-14, Effective: 04-14-14, Implementation 04-14-14)