Any suspected fraud, waste, or abuse in Medicare Part C or Part D should be referred to the NBI MEDIC. Fraud cases may involve beneficiaries, pharmacies, physicians or other providers, health plans, or other organizations.
Timely referrals are necessary to take full advantage of leads in an investigation and as time progresses, important information in a case may become more difficult to track down. The Centers for Medicare & Medicaid Services (CMS) expects Parts C and D Sponsors to initiate referrals for fraud cases within two weeks of detection.
What cases should be referred?
Cases meeting any of the following criteria should be referred to the NBI MEDIC:
- Potential criminal, civil, or administrative law violations
- Allegations extend beyond the PDP/MAPD, involving multiple health plans, multiple states, or widespread schemes
- Allegations involving known patterns of fraud
- Pattern of fraud or abuse threatening the life or well being of beneficiaries
- Scheme with large financial risk to the Medicare Program or beneficiaries
What information should be included in a referral?
Every referral to the NBI MEDIC should contain specifics that will allow an investigator to follow up on a case including basic identifying information and contacts as well as a description of the allegations.
If available, a referral should include:
Your name, organization, and contact information for follow up
Summary of the Issue
- Include the basic who, what, when, where, how, and why
- Any potential legal violations
Specific Statutes and Allegations
- List civil, criminal, and administrative code or rule violations, state and federal
- Provide detailed description of the allegations or pattern of fraud, waste, or abuse
Incidents and Issues
- List incidents and issues related to the allegations
- Contact information for the complainant, the perpetrator or subject of the investigation, and beneficiaries, pharmacies, providers, or other entities involved
- Additional background information that may assist investigators, such as names and contact information of informants, relators, witnesses, websites, geographic locations, corporate relationships, networks
Perspectives of Interested Parties
- Perspective of Plan, CMS, beneficiary
- Existing and potential data sources
- Graphs and trending
- Financial impact estimates
Recommendations in Pursuing the Case
- Next steps, special considerations, cautions
How should the referral be transmitted?
Because specific information may include data protected by HIPAA or the Privacy Act, referrals should be transmitted by one of the following methods:
- Call the NBI MEDIC at 877-7SafeRX and provide the information to our complaint specialists who will key the information into a database, acknowledge and follow up on the complaint.
- If you are reporting potential theft of a beneficiary’s HICN or a prescribers identifier, often called compromised identifiers, please complete and fax a NBI MEDIC Compromised ID Report Form [pdf].
- Complete and fax a Fraud Referral Form [pdf] to the NBI MEDIC at (410) 819-8698 or mail it to:
Health Integrity, LLC
9240 Centreville Rd.
Easton, MD 21601
Attn: NBI MEDIC
Call 877-7SafeRX to verify receipt of the referral and discuss specifics related to the case.
What follow up might occur?
When referring a case, please keep in mind that NBI MEDIC investigators may be contacting you later to discuss details or obtain written documents or other information. Any information related to a potential fraud case should be retained for 10 years.
As an investigation ensues, new leads and data may suggest additional questions or actors involved in a case. Often an initial allegation may be the tip of an iceberg. Be ready to respond as a case develops.
For all cases referred to the NBI MEDIC an acknowledgement letter will be mailed within 5 days and a resolution letter once the case has reached a conclusion. Some cases may take years to be fully resolved and prosecuted.