CMS recently published guidance regarding the Patient Protection and Affordable Care Act's (PPACA) Section 6402(h) regarding a State's suspension of payments pending an investigation of a "credible allegation of fraud." The guidance comes on the heels of CMS's final rule implementing this section of the Act. In essence, CMS has provided States some additional flexibility in determining whether to suspend payments to providers that are suspected of Medicare or Medicaid fraud.
For instance, this guidance confirms that a State need not suspend payments to a provider pending investigation into potential fraud where "good cause" exists. For instance, good cause may exist where the State determines that other remedies might be more effective in protecting Medicaid funds. Similarly, States may waive immediate suspension of payments of a suspected fraudulent provider if that provider furnishes written evidence which persuades the State that suspension should either be terminated or imposed only in part.
This guidance also provides some frequently asked questions about Section 6402(h)'s application. One of the most confusing aspects of this law is what, precisely, constitutes a "credible allegation of fraud"? CMS confirms that this may be any allegation which has been verified by the State and has indicia of reliability from "any" source. Examples of sources include fraud hotline complaints, claims data mining, patterns identified from audits, and law enforcement investigations.
For more information on health care fraud and abuse issues such as Section 6402 of the health care reform law, please contact Mark Bina in Krieg DeVault LLP's Chicago Office at mbina@kdlegal.com or 312-423-9300.
For instance, this guidance confirms that a State need not suspend payments to a provider pending investigation into potential fraud where "good cause" exists. For instance, good cause may exist where the State determines that other remedies might be more effective in protecting Medicaid funds. Similarly, States may waive immediate suspension of payments of a suspected fraudulent provider if that provider furnishes written evidence which persuades the State that suspension should either be terminated or imposed only in part.
This guidance also provides some frequently asked questions about Section 6402(h)'s application. One of the most confusing aspects of this law is what, precisely, constitutes a "credible allegation of fraud"? CMS confirms that this may be any allegation which has been verified by the State and has indicia of reliability from "any" source. Examples of sources include fraud hotline complaints, claims data mining, patterns identified from audits, and law enforcement investigations.
For more information on health care fraud and abuse issues such as Section 6402 of the health care reform law, please contact Mark Bina in Krieg DeVault LLP's Chicago Office at mbina@kdlegal.com or 312-423-9300.
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