Case developed after the program safeguard contractor (PSC) has substantiated an allegation of fraud.

Maximum anticipated total payments (based on the most recent year’s utilization and experience and any current or anticipated factors that may affect payment amounts) that could be received if use or costs of referral services were low enough. These payments include amounts paid for services furnished or referred by the physician/group, plus amounts paid for administrative costs. Payments not included in potential payments include bonuses or other compensation not based on referrals (e.g., bonuses based on patient satisfaction or other quality of care factors).