Under a provision in the healthcare reform law, CMS may suspend payments to a provider if it suspects fraud, according to a report in the RAC Monitor.
In proposed regulations issued in Sept. 2010, CMS said Medicare payments may be suspended, pending an investigation, if "a credible allegation of fraud exists against a provider or supplier," wrote Amy K. Fehn and Jennifer Colagiovanni, attorneys at Wachler & Associates. The allegation would be considered "credible" when they have "indicia of reliability," they added.
If fraud is suspected, CMS contractors can suspend the provider's payments and the provider is notified after the suspension is implemented. Providers are not allowed to appeal a payment suspension, but they can file a rebuttal statement with CMS to explain why the agency should remove the suspension.
The rebuttal statement must be filed within 15 days of the date of the suspension notification letter. CMS contractors are instructed to respond within 15 days of receipt. However, few providers with suspensions submit rebuttals to CMS and, of those, few rebuttals result in CMS lifting the suspension.
Payments are typically suspended for a period of 180 days, but CMS may extend the time period. During the payment suspension, providers may continue to submit claims to their Medicare contractor, but payments will be held in suspense, thus eliminating cash flow.
Read the RAC Monitor report on fraud.
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