Medicare Payment Suspension Lawyer in Texas

Comprehensive Counsel for Medicare Compliance

The Centers for Medicare & Medicaid Services (CMS) uses many tools to deter waste, fraud, and abuse among providers and suppliers who bill Medicare and Medicaid.

In addition to billing privilege revocations and recoupment, CMS has the authority to suspend payments to providers or suppliers under any of the following three circumstances:

  1. Fraud or willful misrepresentation;
  2. Identified overpayment for which an amount has not yet been determined;
  3. Potentially improper or incorrect payments that have been made or will be made; or
  4. The provider or supplier fails to furnish records and other requested information needed to determine amounts due.

Payment suspensions can create immediate financial concerns for providers, as well as exposure to further enforcement action. If your practice or medical business has had payments suspended by CMS or is facing any health care audit or investigation, a timely and strategic response is vital.

At Hendershot Cowart P.C., our health and medical law team provides the comprehensive support providers need following a Medicare payment suspension. This includes assistance with billing and compliance issues and defense against fraud allegations and devastating penalties. We serve clients across Texas and the U.S., and are immediately available to help.

Medicare Payment Suspensions Explained

CMS may suspend Medicare payments upon requests from contractors or government regulators in cases involving overpayments, incorrect payments, or potential fraud. The vast majority of suspensions are issued due to behaviors and patterns that suggest fraud.

  • Improper payments: CMS contractors may request payment suspensions when overpayments have been identified but not yet calculated, or when payments have been made but may not be correct. Program Safeguard Contractors and Zone Program Integrity Contractors (ZPIC) are CMS contractors that typically request payment suspensions.
  • Fraud: Under the Affordable Care Act (ACA), payments can be suspended when providers are credibly accused of fraud, unless CMS finds a justifiable reason not to suspend payments. In determining whether credible fraud allegations exist, the ACA requires that CMS consult with the United States Department of Health and Human Services’ Office of Inspector General (OIG). Providers who are “credibly” accused of fraud are typically given no advance notice prior to payment suspensions.

According to the OIG, Medicare and Medicaid account for some of the largest improper payments in federal government programs. An OIG analysis and Management and Performance report highlight CMS’ top areas of focus when implementing payment suspensions:

  • Per the OIG and CMS, improper payments are most common among Part B, home health, chiropractic care, and DME claims.
  • A majority of suspensions involve providers with questionable billing patterns.
  • Over half of suspensions are supported by evidence from other providers or from Medicare beneficiaries, including evidence of billing for services not rendered, unauthorized services, or medically unnecessary services.

As the data shows, Medicare payment suspensions are used primarily to combat health care fraud. This means providers who have payments suspended face significant exposure to additional investigation and enforcement that can put considerable civil monetary penalties or prison time on the table. If you have received notice of a payment suspension, the time to act is now.

Payment Suspension Process

Regardless of how a suspension arises, they must be accompanied by a suspension notice that explains the reason for suspension, the extent of the suspension (i.e. all claims or partial suspension), when the suspension will begin and how long it will remain in effect. This notice may be sent prior to suspension in the case of improper payments, or after a suspension in cases of fraud or willful misrepresentation.

Unlike most CMS actions, a Medicare payment suspension is not appealable. Instead, providers have the right to submit a rebuttal statement within 15 days of the suspension notice.

Other key points about Medicare payment suspensions:

  • Suspension duration: Payments are generally suspended for a period of 180 days, but may be extended an additional 180 days or indefinitely (in the case of OIG administrative action) when regulators are considering further enforcement action for health care fraud, or when contractors require additional time to conduct overpayment calculations.
  • Overpayment calculations: During a suspension, CMS contractors will calculate overpayments for all claims in a specific time period determined to have been paid incorrectly. Contractors will select a sample of claims and review records to determine the overpayment amount. If providers fail to provide records, contractors will determine all claims were paid in error.
  • Submitting claims during suspension: During a suspension, providers may continue submitting claims. Payments for valid claims submitted during suspension will be withheld and used to reduce the amount of overpayment and any other debts owed to CMS or HHS. Any remaining payments after overpayment and debts have been satisfied are released to providers.
  • Suspension removal: Suspensions are removed once overpayment is calculated, a demand letter is issued, and suspended payments are applied to the final overpayment amount and / or released to the provider.

Decades of Experience in Health & Medical Law

Medicare payment suspensions may seem like a simple mechanism for correcting overpayment, but they can have immediate financial repercussions for physicians, medical practices, and health care businesses. Because they also pose risks of health care fraud investigations and serious penalties, payment suspensions demand the timely attention of qualified health care lawyers.

At Hendershot Cowart P.C., our attorneys draw from decades of experience to guide health care clients through challenging enforcement actions, audits, and investigations. We take a team approach to exploring risk-mitigating solutions, and can assist providers and suppliers in responding to suspension notices, addressing matters of regulatory compliance and billing practices, and waging a strategic defense.

To speak with an attorney, call or contact us online.

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