Medicare Payment Suspension Defense Attorneys | Texas & Nationwide

If your Medicare payments have been suspended, you have a narrow window to respond and only one opportunity to present your case. Unlike most Center for Medicare & Medicaid Services (CMS) enforcement actions, a Medicare payment suspension cannot be appealed. Your only procedural right is to submit a written rebuttal – and you have 15 days from receipt of the suspension notice to do it.

A poorly prepared rebuttal, or no rebuttal at all, increases the risk of a formal overpayment determination, billing privilege revocation, or referral to the Department of Justice or OIG. 

At Hendershot Cowart P.C., our healthcare law attorneys defend physicians, medical practices, hospice providers, home health agencies, DME suppliers, and other Medicare-enrolled providers facing payment suspensions, UPIC investigations, and CMS enforcement actions across Texas and throughout the United States. Call (713) 783-3110 for immediate assistance.

On This Page

• Is This Page for You?
• What Is a Medicare Payment Suspension?
• What Triggers a Medicare Payment Suspension?
• Which Providers Are Most at Risk of Medicare Payment Suspensions?
• Can You Appeal a Medicare Payment Suspension?
• What to Do If Your Medicare Payments Are Suspended
• What Are the Possible Outcomes of a Medicare Payment Suspension?
• How We Defend Providers Against Payment Suspensions
• Payment Suspension vs. Recoupment vs. Billing Privilege Revocation
• Frequently Asked Questions
• Facing a Medicare Payment Suspension? Contact Hendershot Cowart P.C. Today.

Is This Page for You?

This page is for Medicare-enrolled healthcare providers and suppliers – physicians, medical practices, hospice agencies, home health providers, DME suppliers, hospitals, and other entities that bill Medicare – whose reimbursement payments have been suspended by CMS or a Medicare contractor.

If you are a Medicare beneficiary whose personal Medicare coverage or benefits have been affected, this page does not cover your situation. Contact Medicare directly at 1-800-MEDICARE (1-800-633-4227) or visit medicare.gov for assistance with your individual coverage.

What Is a Medicare Payment Suspension?

A Medicare payment suspension is the withholding of Medicare reimbursements to a provider or supplier – before any overpayment has been calculated or formally determined – while CMS or its contractors investigate a potential problem with your billing.

A suspension is not a routine audit or a billing dispute. It is an immediate freeze on your Medicare income, effective on the date stated in the notice, with no automatic end date.

Suspensions are issued by CMS or by Unified Program Integrity Contractors (UPICs) – such as Qlarant Integrity Solutions in the Southwestern jurisdiction, which covers Texas – acting on CMS's behalf. During a suspension, claims continue to be processed but payments are withheld. The withheld funds are later applied to any determined overpayment or released to the provider once the suspension is lifted.

What Triggers a Medicare Payment Suspension?

CMS may suspend Medicare payments under four circumstances:

1. Credible allegation of fraud. The most serious – and most common – basis for suspension. Under the Affordable Care Act, CMS may suspend payments immediately when it determines that a credible allegation of fraud exists, after consulting with the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG) and, where appropriate, the U.S. Department of Justice (DOJ). A credible allegation of fraud can be established through claims data mining alone. CMS does not need to interview patients, complete a field investigation, or calculate an overpayment before suspending payments.
2. Identified overpayment – amount not yet determined. CMS or a Medicare contractor has determined that an overpayment exists but has not yet calculated the precise amount. Payments are suspended while that calculation is completed.
3. Potentially incorrect payments. CMS or a contractor has reliable information that payments are or may be incorrect, even if no overpayment has been formally identified.
4. Failure to furnish requested records. A provider or supplier fails to submit documentation requested by a Medicare contractor to determine amounts due.

The vast majority of payment suspensions are issued under the credible allegation of fraud standard. Providers who fall into this category typically receive no advance notice – the suspension is already in effect when the letter arrives.

Which Providers Are Most at Risk of Medicare Payment Suspensions?

Payment suspensions are concentrated among providers with billing patterns that deviate significantly from national norms. Home health agencies, hospice providers, durable medical equipment (DME) suppliers, and high-volume Part B billers face elevated scrutiny. 

In Texas, hospice providers are currently a priority enforcement target – CMS Administrator Dr. Mehmet Oz identified Texas as a growing focus for program integrity efforts in April 2026, following aggressive enforcement actions in California.

Can You Appeal a Medicare Payment Suspension?

No. A Medicare payment suspension cannot be appealed.

There is no administrative hearing, no Administrative Law Judge review, and no formal Medicare claims appeals process available to challenge payment suspension. You cannot appeal your way out of a suspension. The rebuttal is the only tool available.

A rebuttal is a written response – submitted within 15 calendar days of the suspension notice – presenting specific evidence that the suspension is not warranted or that good cause exists for it to be discontinued or limited in scope. The Medicare contractor reviews the rebuttal, prepares a response, and submits both to CMS for approval. The Medicare contractor must send written notice of its final determination in response to the rebuttal within 15 days of receipt. That determination is not appealable. 

A well-constructed rebuttal serves several functions:

• It creates a formal record with CMS that can support your position in subsequent proceedings
• It opens a direct channel of communication with the contractor and CMS
• It may support an argument for a partial suspension rather than a full payment hold
• In our experience, a well-supported rebuttal signals to CMS that the provider has a credible defense – which can reduce the likelihood of escalation to a formal overpayment proceeding or referral to DOJ or OIG

The rebuttal is the most consequential document your practice will produce in response to a suspension notice. It must be treated as a legal argument, not a records submission.

What to Do If Your Medicare Payments Are Suspended

1. Do not ignore the letter. The 15-day rebuttal window begins running from the date you receive the letter. The 30-day documentation deadline runs from the date on the letter. Missing either deadline worsens your position.
2. Do not respond without legal counsel. The rebuttal is your only procedural recourse. It needs to be specific, strategic, and supported by evidence that directly addresses each factual basis for the suspension. General denials will not succeed.
3. Preserve all relevant documentation immediately. Once you receive a suspension notice, you have a legal obligation to preserve all potentially relevant records – patient medical records, billing records, certification documentation, staff communications, compliance policies, and training materials. Destroying or altering records after receiving notice of a government investigation can result in separate criminal obstruction charges.
4. Do not discuss the investigation broadly. Limit discussion to those who need to know. Information shared with staff, colleagues, or patients can be discovered through interviews and subpoenas.
5. Call a healthcare attorney the day the letter arrives. Early intervention improves your chances of a favorable outcome. An experienced attorney can evaluate the suspension, construct a defensible rebuttal, manage the documentation request, and position your practice for the best possible resolution before the investigation deepens.

What Are the Possible Outcomes of a Medicare Payment Suspension?

A payment suspension is not a final enforcement action – it is the beginning of a process that can move in several directions depending on what CMS and Qlarant find when they examine your billing records. The outcome depends heavily on how quickly you respond and how effectively you respond.

Here are the possible outcomes of a Medicare payment suspension:

• The suspension is lifted, and payments are released. This is the best-case outcome. It occurs once Qlarant calculates the overpayment, the Medicare claims processor issues a demand letter, and suspended payments are applied to the determined overpayment or released to the provider. A well-constructed rebuttal can also result in a lifted or reduced suspension. 
• The suspension continues – for months or longer. Suspensions are generally limited to 180 days, but that limit has exceptions. CMS must re-evaluate every 180 days whether good cause exists to continue a fraud-based suspension. If the investigation is not resolved within 18 months, good cause to end the suspension is deemed to exist automatically – unless DOJ has submitted a written request to continue it based on an ongoing investigation, or the case has been referred to OIG for administrative action. If either condition applies, the suspension continues with no fixed end date. In practice, any case involving active federal law enforcement participation can extend well beyond 18 months.
• The suspension escalates to a formal overpayment demand. Once Qlarant finishes its review, it will calculate an overpayment for claims it determines were paid incorrectly. That overpayment – which may be extrapolated from a sample of claims to your entire billing history – becomes the basis for a demand letter and recoupment action. At that stage, the full Medicare appeals process becomes available, from redetermination through federal court.

See our Medicare Overpayment & Recoupment Defense page for information on what happens after the suspension is lifted and an overpayment demand is issued.

• Your Medicare billing privileges are revoked. This is the most serious administrative outcome short of criminal referral. A first-time revocation carries a reenrollment bar of one to ten years. Repeat offenders face bars of up to 20 years. Revocation means your agency cannot bill Medicare for the duration of that bar, regardless of whether the underlying overpayment is resolved.
• The case is referred to DOJ or OIG for criminal or civil action. If the investigation produces evidence of intentional fraud – as opposed to billing errors or documentation deficiencies – the case can be referred for criminal prosecution, False Claims Act civil action, or OIG exclusion from all federal health care programs. Preventing referral is often the most important function experienced Medicare fraud legal counsel serves in the early stages of a suspension.

Which of these outcomes you face depends in large part on what happens in the first 15 days.

How We Defend Providers Against Payment Suspensions

Hendershot Cowart P.C. represents physicians, medical practices, hospice providers, home health agencies, DME suppliers, and other Medicare-enrolled providers facing payment suspensions across Texas and throughout the United States. Our healthcare law attorneys have more than 150 years of collective legal experience defending providers against CMS enforcement actions, UPIC investigations, and Medicare fraud allegations.

When you contact us about a Medicare payment suspension, we immediately:

• Evaluate the suspension notice and assess the strength of the underlying allegations
• Analyze the billing and clinical data CMS relied on to identify weaknesses in the government's position
• Prepare a strategic rebuttal within the 15-day deadline that directly and specifically addresses each factual basis for the suspension – with supporting clinical evidence and documentation
• Manage the additional documentation request in a way that supports, rather than complicates, your defense
• Work to limit the scope of the suspension – pursuing a partial suspension rather than a full payment hold where appropriate
• Monitor for escalation to overpayment determination, billing privilege revocation, or referral to DOJ or OIG – and intervene proactively at each stage
• Navigate subsequent proceedings including overpayment appeals, recoupment negotiations, and, where necessary, the full Medicare administrative appeals process

We serve providers in all 50 states, with particular depth in Texas – including familiarity with Qlarant Integrity Solutions and its current enforcement priorities in the Southwestern jurisdiction.

Payment Suspension vs. Recoupment vs. Billing Privilege Revocation

These three enforcement tools are often confused – and they carry different consequences, timelines, and response options.

A single enforcement action can involve all three. A UPIC investigation may trigger a payment suspension, which is followed by an overpayment determination and recoupment demand, which in turn supports a billing privilege revocation. Understanding which stage you are in determines what options are available to you.

Frequently Asked Questions

What is a Medicare payment suspension? 

A Medicare payment suspension is the withholding of Medicare reimbursements to a provider or supplier while CMS or its contractors investigate a potential billing problem. It is not a routine audit. Payments are frozen – often with no advance notice – until the investigation is resolved and an overpayment is calculated or the suspension is lifted.

What is a credible allegation of fraud? 

A credible allegation of fraud is an allegation from any source – including claims data mining, fraud hotline tips verified by further evidence, or patterns identified through audits or law enforcement investigations – that appear to be reliable. CMS does not need to complete an investigation before suspending payments under this standard.

Can I appeal a Medicare payment suspension?

No. A Medicare payment suspension is not subject to the standard Medicare administrative appeals process. There is no right to a hearing before an Administrative Law Judge. Your only procedural right is to submit a written rebuttal within 15 calendar days of the suspension notice.

What is a rebuttal and how does it work? 

A rebuttal is a written response to a suspension notice presenting specific evidence that the suspension is not warranted or should be lifted. The Medicare contractor reviews the rebuttal and submits a proposed response to CMS for approval. The suspension remains in effect while the rebuttal is under review. The determination following the rebuttal review is not appealable.

Can I still submit claims during a suspension? 

Yes. You may continue to submit claims during a suspension. Payments on valid claims submitted during the suspension period will be withheld and applied to any determined overpayment and other debts owed to CMS. Any remaining balance after those obligations are satisfied is released to you.

How long does a Medicare payment suspension last? 

Suspensions are generally limited to 180 days, with extensions available by written request from Qlarant, OIG, or DOJ. If your case is referred to OIG for administrative action – such as exclusion or civil monetary penalties – the time limits no longer apply and the suspension may continue indefinitely. The suspension is removed once an overpayment is calculated, a demand letter is issued, and suspended funds are applied or released.

What is Qlarant, and why did I receive a letter from them? 

Qlarant Integrity Solutions, LLC is the Unified Program Integrity Contractor (UPIC) for the Western and Southwestern jurisdiction, which includes Texas and 19 other states. UPICs are federal contractors hired by CMS to investigate suspected fraud, waste, and abuse among Medicare and Medicaid providers. A letter from Qlarant means your billing has been flagged for investigation – it is not a routine audit notice. See our UPIC Audit Defense page for more information.

What happens after the suspension is lifted? 

Once the suspension is removed, suspended funds are applied first to any determined overpayment and accrued interest, then to any other debts owed to CMS or HHS. Any remaining balance is released to the provider. The lifting of the suspension does not end the investigation – overpayment proceedings and potential enforcement actions may continue.

Facing a Medicare Payment Suspension? Contact Hendershot Cowart P.C. Today.

If your Medicare payments have been suspended – or if you have received a letter from Qlarant, SafeGuard Services, CoventBridge, or another UPIC – contact Hendershot Cowart P.C. immediately. You have 15 days to submit a rebuttal. Early legal intervention significantly improves your chances of a favorable outcome.

We represent providers across Texas and throughout the United States. Call (713) 783-3110 or contact us online to speak with a healthcare attorney today.