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Payment Suspension (allowed for Medicare and Medicaid funds) - Advantage CMS!

April 5, 2016


Question:


Jennifer, 

I received a letter from Safeguard Services that CMS is suspending my Medicare payments. Is this for real? I was audited a few years ago and had to pay back a de minimis amount.  Could this be related?   

Dr. L


Answer:

Dr. L, this is for real. Since 1996 federal regulations have existed authorizing payment suspension for suspected fraud or willful misrepresentation. You may be thinking, okay, well if someone committed fraud or if a system of checks allows for payment suspension for fraud, I get that. That makes sense. Well, the statutes have evolved and now fraud is not necessary to warrant payment suspension.  As the relevant payment suspension statute reads now, 42 CFR s 405.371, payments may be suspended in whole or in part by CMS or a Medicare contractor where "reliable information that an overpayment exists or that the payments to be made may not be correct, although additional information may be needed for a determination".  So, sub (1) of s. 405.371 allows for a mere inkling by CMS or its contractor (paid on percentage of recoupments) to warrant payment suspension.  

Other reasons a suspension may be "warranted" according to CMS - 

(2) suspected fraud

(3) to offset or recoup payments where an overpayment has occurred (as determined by CMS)

The suspension you are facing may very well be related to the prior audit.  You likely are receiving or will receive pre-payment review requests.  

Do not wait to have this addressed.  Let's discuss offline the necessary response and next steps.  CMS is authorized to suspend payments for 180 days, with the ability to continue past that time frame. Most practices or vendors would be easily out of business by then. 

For those readers this avenue of "relief" available to the government is news to, this is one of many mechanisms that gives the government (and payors in general) an unfair advantage in the reimbursement chain. 

For those academically inclined, the public had an opportunity to comment on proposed payment suspension legislation.  Here is the most recent opportunity - 76 FR 5961(scroll to page 68, FR page 5928).  

 


 
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