Optional_2023 Board Resources

(ii) In cases of suspected fraud, after consultation with the OIG, and, as appropriate, the DOJ, it is determined that a credible allegation of fraud exists against a provider or supplier, unless there is good cause not to suspend payments. 105 CMS may find that good cause exists not to suspend payments or not to continue to suspend payments where there are credible allegations of fraud if: (i) Suspension may compromise or jeopardize an investigation by OIG or another law enforcement agency; (ii) Beneficiary access to items or services would be so jeopardized by suspension as to cause a danger to life or health; (iii) Other available remedies more effectively or quickly protect Medicare funds; or (iv) CMS determines suspension is not in the best interests of the Medicare program. To suspend payments, CMS or the MAC must comply with certain procedural requirements; namely, providing notice of the intention to suspend payments and the reasons for the suspension. 106 A suspension of payment may be imposed without prior notice in some circumstances; e.g., if CMS determines that prior notice is not appropriate in suspensions involving credible allegations of fraud. If prior notice is required, the provider or supplier has an opportunity for rebuttal before the suspension goes into effect. 107 If prior notice is not required, once the suspension is in effect, the provider or supplier can submit a rebuttal as to why the suspension should be removed. A suspension of payment is limited to 180 days, starting with the date the suspension begins. The investigating party may request a one-time extension of the suspension for up to 180 additional days if it is unable to complete its examination or investigation within the time limit. CMS determines whether the extension is appropriate. This time limit does not apply if the suspension of payments is based upon credible allegations of fraud. In that case, CMS re- evaluates the suspension every 180 days to determine if it should continue. Good cause not to continue to suspend payments to an individual or entity against must be deemed to exist if a payment suspension has been in effect for 18 months and there has not been a resolution of the investigation. In that situation, CMS may extend a payment suspension beyond that point only if the case has been referred to the OIG for administrative action or the DOJ submits a written request to CMS that the suspension be continued based on an ongoing investigation. 7.2 Revocation. 108 CMS may revoke a currently enrolled provider or supplier’s Medicare billing privileges and any corresponding provider agreement or supplier agreement for the following reasons:

105 CMS or the MAC can offset or recoup Medicare payments to providers or suppliers under this rule if it is determined that the provider or supplier to whom payments are to be made has been overpaid. MACs can also suspend payments in cases of unfiled cost reports and unfiled hospice cap determination reports. 106 See 42 C.F.R. § 405.372. 107 See 42 C.F.R. § 405.374. 108 See 42 C.F.R. § 424.535; HHS, CMS, Medicare Program; Requirements for Providers and Suppliers To Establish and Maintain Medicare Enrollment , 71 Fed. Reg. 20754 (Apr. 21, 2006).