By: Matt Fischer
Medicare payment suspension can place serious financial strain on a company’s operations. As a result, many companies face the risk of closing its doors when a suspension is initiated. Nevertheless, CMS is able to issue such suspensions by meeting a relatively low threshold. Additionally, suspension decisions are not appealable leaving affected providers and suppliers with little options. Therefore, it is important to understand the suspension process and how to counter if a notice of suspension is received.
CMS can suspend payments to providers and suppliers based on “reliable information” of any of the following: (1) fraud or misrepresentation; (2) when an overpayment exists but the amount has not yet been determined; (3) when reimbursement paid to a provider or supplier may be incorrect; or (4) when a provider or supplier fails to submit requested records needed to determine amounts due. Suspensions are initiated by a request to CMS’ Office of Program Integrity by either law enforcement or a Medicare administrative contractor.
The process of requesting a Medicare payment suspension is the same whether it is from a contractor, law enforcement, or CMS itself. Typically, a Medicare contractor will send a request to CMS along with a draft notice of suspension letter. Under Medicare regulations and policy, this notice is required to provide the specific reason for the suspension to allow the provider or supplier to identify the problem. In addition, the notice must also include other information such as the start date of the suspension, the extent of the suspension (i.e., all claims or only a portion), and the length of the suspension. However, unlike most decisions from CMS, a Medicare payment suspension is not appealable. The only recourse a provider or supplier is given is the opportunity to rebut. A rebuttal must be submitted within 15 days of receipt of the notice of suspension.
If a suspension is initiated, a provider or supplier may continue to submit claims. For all approved claims, the amounts will be withheld and either applied to an existing overpayment or released upon termination of the suspension. Suspensions usually last 180 days. However, extensions may be granted but the amount of time will depend on whether it was requested by a contractor or law enforcement.
CMS has issued transmittals on how to understand the payment suspension process. However, even with this guidance, providers and suppliers should take action to ensure sufficient funds are available to continue operations if a suspension is initiated. In addition, providers and suppliers should be ready to prepare a comprehensive rebuttal that fully addresses CMS’ concerns in order to counter the suspension decision.