Common Misunderstandings About Medicare/Medicaid Fraud and Abuse

Providers are generally familiar with prohibitions against fraud and abuse in the Medicare and Medicaid Programs, including Medicaid waiver programs, and other state and federal health care programs, such as the VA and TriCare. Private insurers now often enforce the same prohibitions applicable to federal and state programs. But there are at least two common misconceptions about fraud and abuse, as follows:


(1) Enforcers must prove intent in order to show that providers engaged in fraud, but providers may not understand what the government can use to show “intent.”


Many providers seem to think that the only way to show intent is to prove that they sat down at their desks on a Monday morning and decided to commit fraud, but court decisions tell a very different story! They say that if enforcers can prove that providers knew or should have known of a pattern of fraudulent conduct, enforcers may conclude that providers had intent. Other court decisions say that when providers show reckless disregard for a pattern of fraudulent conduct regulators can show intent necessary to prove fraud.


When providers grasp these crucial standards, it is clear that they must become vigilant to prevent patterns of fraud and abuse. This is necessary in order to prevent government enforcers from concluding that they had intent necessary to prove fraud and/or abuse.



(2)Many providers also may not understand that every provider, regardless of position, is personally responsible for fraud and abuse compliance. It is extremely tempting to think that fraud and abuse compliance is management’s responsibility, or the exclusive job of the Administrator/Chief Executive Officer or the organization’s Compliance Officer.


On the contrary, the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services, the primary enforcer of fraud and abuse prohibitions, is quite clear that every practitioner has personal, individual responsibility for fraud and abuse compliance. The OIG has taken this position because it realizes that the problem of fraud and abuse will never be solved until every practitioner takes individual responsibility for it. Enforcement action is often taken against individual practitioners, as well as members of management and owners.


When providers understand these two basic points, they are well along the road to active participation in fraud and abuse compliance efforts. Providers must remember that fraud and abuse compliance is now a permanent part of the health care landscape across the nation. Compliance is not a fad that will blow over or disappear! Providers must be prepared to actively work to prevent or correct fraud and abuse for as long as they work in the healthcare industry.



©2020 Elizabeth E. Hogue, Esq.  All rights reserved

Read More
Southern Web SupportCommon Misunderstandings About Medicare/Medicaid Fraud and Abuse

Review Choice Demonstration

The U.S. Centers for Medicare & Medicaid Services (CMS) announced Friday it will not resume a full-blown resumption of the Review Choice Demonstration (RCD) for home health agencies in participating states later this month. Instead, CMS is “phasing in” RCD for agencies in North Carolina and Florida. Agencies in Illinois, Ohio and Texas will be:

Read More
Review Choice Demonstration

Discharge Planners Must Stop Accepting Kickbacks and Managers Must Monitor Receipt

Case managers/discharge planners have recently come under fire from fraud enforcers for violations of the federal anti-kickback statute. This statute generally prohibits anyone from either offering to give or actually giving anything to anyone in order to induce referrals. Case managers/discharge planners who violate the anti-kickback statute may be subject to criminal prosecution, which may result in prison sentences, among other consequences.


Federal Criminal Complaints were recently filed against thirty defendants in the San Francisco area who were charged in a “patients-for-cash” kickback scheme. The complaints centered on Amity Home Health Care, the largest home health care provider in the Bay Area, and Advent Care, Inc., a hospice. Under the leadership of Ridhima “Amanda” Singh, Chief Executive Officer, the federal government claims that Amity and Advent paid kickbacks to discharge planners/case managers at hospitals and social workers at skilled nursing facilities (SNFs), among others, in exchange for referrals.


The Criminal Complaints say that discharge planners/case managers in hospitals and SNFs received the following in exchange for referrals of home health and hospice patients:

·       Cash periodically delivered in envelopes

·       Gift cards ranging in value from $2,000 to $5,000

·       Handbags from Gucci, Louis Vuitton and Nordstrom

·       All-expenses-paid trips to Napa, California

These alleged payments and gifts clearly violate the federal anti-kickback statute.


Most recently, a Registered Nurse (RN) in California pled guilty to conspiring with owners of home health agencies to pay and receive illegal kickbacks in exchange for referrals of Medicare patients. The RN, who was a case manager at a nonprofit hospital, used his position as a discharge planner to steer Medicare patients to home health agencies who paid kickbacks to him.


The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS), the primary enforcer of fraud and abuse prohibitions, says that discharge planners cannot accept the following from providers who want referrals:

·       Cash

·       Cash equivalents, such as gift cards or gift certificates

·       Non-cash items of more than nominal value

·       Free discharge planning services that case managers/discharge planners are obligated to provide

The services provided by discharge planners/case managers are extremely important and are valued by many patients and their families, but the credibility and trustworthiness of discharge planners/case managers is destroyed when discharge planners/case managers make referrals based on kickbacks received.


Now a word to managers and all the way up the chain of command to CEOs. Whether or not you know that case managers/discharge planners are accepting kickbacks, the OIG may also hold you responsible. The OIG has made it clear that your job is to monitor and to be vigilant. If you knew or should have known, you may be responsible. A good starting point is to put a policy and procedure in place that requires discharge planners/case managers to report in writing anything received from post-acute providers. Or how about a policy and procedure that prohibits all gifts?!


Now a word to post-acute marketers. Don’t give kickbacks to discharge planners/case managers! It’s simply not true that you must give kickbacks in order to get referrals. The proverbial bottom line is: Do you like the color orange? Is orange your preferred fashion statement?


Please stop now!



©2020 Elizabeth E. Hogue, Esq.  All rights reserved

Read More
Southern Web SupportDischarge Planners Must Stop Accepting Kickbacks and Managers Must Monitor Receipt

Recent Fraud Enforcement Action: Lessons for Providers

According to a July 23, 2020, press release, Progenity, Inc., fraudulently overbilled Medicaid and the VA by using a billing code that misrepresented the tests performed. Fraud enforcers also claim that Progenity provided illegal kickbacks in the form of excessive fees to physicians, meals and happy hours for physicians and their staff members, and improper reductions or waivers of patients’ coinsurance and deductible payments. The “price tag” for Progenity: $49 million! Enforcement action was taken against Progenity by multiple state and federal health care programs; including the VA, various state Medicaid Programs, TRICARE, and the Federal Employees Health Benefits Program.


FIRST LESSON: FRAUD AND ABUSE PROHIBITIONS APPLY TO ALL FEDERAL AND STATE HEALTH CARE PROGRAMS, NOT JUST THE MEDICARE PROGRAM. This means, for example, that companies that provide private duty services that may be paid for, at least in part, by any federal or state healthcare program must comply with the federal False Claims Act and the Anti-Kickback Statute, and applicable state requirements. Many private insurers have followed the federal government’s lead in terms of fraud and abuse enforcement.


The government also alleges that Progenity induced physicians to order lab tests by providing kickbacks. This claim was based on the fact that the “draw fees” that Progenity paid to physicians to draw blood for lab tests exceeded the fair market value of the services performed.


SECOND LESSON: PROVIDERS MUST PAY PHYSICIANS AT FAIR MARKET VALUE FOR SERVICES ACTUALLY RENDERED. Providers must address the issue of payments at fair market value to physicians who both make referrals and provide services to them. The most effective way for many providers to meet this requirement is to pay physicians at an hourly rate at fair market value for services actually rendered. In other words, flat monthly amounts are likely inappropriate because providers run the risk of payment for services that were not rendered or payments for services at rates above fair market value.


Progenity also provided kickbacks in the form of food and alcohol to physicians and their staff at “gatherings,” including happy hours and holiday parties. There was rarely any educational content provided during these events. One sales representative for Progenity, for example, spent $65,658 on meals and alcohol for physicians during a single year.


THIRD LESSON: PROVIDERS’ GIFTS OF NOMINAL VALUE TO PHYSICIANS CANNOT EXCEED THE CURRENT FEDERAL LIIMIT OF $423.00 PER YEAR AND ANY STATE LIMITATIONS. Providers may give referring physicians non-cash, non-monetary equivalent items of nominal value worth no more than $423.00 per calendar year. Monetary equivalents include gift cards and gift certificates. Providers must track what they give physicians to help ensure that they do not exceed this limit. Enforcers have repeatedly said that providers are responsible to show how much they spent.


Progenity provided kickbacks to patients in the form of waivers of coinsurance and deductible payments and had agreements with physicians to do so on a regular basis.


FOURTH LESSON: PROVIDERS CANNOT ROUTINELY WAIVE CO-PAYMENTS AND DEDUCTIBLES UNLESS THEY MAKE INDIVIDUALIZED DETERMINATIONS OF FINANCIAL NEED AND/OR MAKE REASONABLE COLLECTION EFFORTS. This means that providers must have policies and procedures that govern the waiver of co-payments and deductibles, including criteria that are used to determine financial need. These policies and procedures must be consistently applied.


The information above isn’t new. Enforcement actions on the bases described above are “low hanging fruit.” Make it tougher for enforcers to take action by taking the steps described above!



©2020 Elizabeth E. Hogue, Esq.  All rights reserved.

Read More
Southern Web SupportRecent Fraud Enforcement Action: Lessons for Providers

Seriously Ill COVID-19 Patients at Home

In view of recent spikes in COVID-19 cases, there is continuing concern that hospitals will be overwhelmed with severely ill patients and that beds in intensive care units (ICUs) may become unavailable. Perhaps the answer is to keep as many patients as possible, even those who are seriously ill, at home.


You may have read an article in The New York Times on July 26, 2020, entitled “Some Seriously Ill Patients Can Be Treated at Home” by Roni Caryn Rabin. The subject of the article, Joan Murray, is seventy-seven years old and a retired registered nurse (RN). She was ill with COVID-19 for about a week when she ran into serious trouble. She had a fever of one hundred and three degrees and her oxygen levels were dropping. She was having trouble breathing and said it felt “as if somebody had bound up [her] lungs with string.”


Ms. Murray was adamant that she wanted to be treated at home, so Northwell Hospital sent a nurse manager to her home who did a thorough assessment. In short order, Ms. Murray was on IV fluids. A phlebotomist came to her home to draw blood. Ms. Murray was placed on oxygen and was started on a powerful blood thinner to prevent clots. During the following week, nurses visited daily. A critical care physician and lung specialist also called each day to talk with Ms. Murray. Pulmonologists used remote monitoring to follow Ms. Murray.


Provision of care at home is often consistent with patients’ decisions to refuse hospitalization. Patients like Ms. Murray may be fearful about going to hospitals and very concerned about being cut off from friends and family, since visitors are generally barred by health facilities to prevent further spread of the virus. Hospitals like the one that treated Ms. Murray have now developed evidenced-based protocols that rely on educating patients about how to monitor their temperature fluctuations, track blood oxygen levels, use pulse oximeters and report changes to practitioners. These protocols require that patients in severe respiratory distress will be hospitalized.


Between April 27th and June 1st, Northwell treated one hundred and eighty-two COVID-19 patients, ranging from ages twenty-four to one hundred, in its home care programs. Many had underlying conditions, such as diabetes, that are linked to worse outcomes. Most patients, including Ms. Murray, were able to remain at home during treatment of their illnesses. Only two patients were eventually hospitalized. Patients cared for at home also received needed services at home after they recovered, including nursing, therapy and private duty services.


Based upon the above, home care providers may become front-line providers in the fight against COVID-19. Home care providers have the knowledge and experience to fulfill this role. Get ready!



©2020 Elizabeth E. Hogue, Esq.  All rights reserved.

Read More
Southern Web SupportSeriously Ill COVID-19 Patients at Home

First, Do No Harm

“First, do no harm” is the primary directive for all healthcare practitioners. Achieving this goal at this time certainly requires vigilance, both personal and professional, on the part of all practitioners. Some commentators have suggested anecdotally that healthcare practitioners may be a significant vector of transmission of the coronavirus.


In an article in The New York Times on February 26, 2020, entitled “Shaved Heads, Adult Diapers: Life as a Nurse in the Coronavirus Outbreak,” Nurse Zhang Wendan reported that she and her colleagues were required to live in the hospital where they worked for thirty consecutive days. They then quarantined for an additional fourteen days before returning home.


Likewise, Italian physicians raised the question in early reports about whether patients should be kept at home when diagnosed with coronavirus with intensive remote monitoring. They suggested that in-person care at home should be provided by a mobile team dedicated to the care of coronavirus patients and that only the most severely ill patients should be hospitalized.


In “Bringing the Hospital Home to Patients,” by Gurvinder Kaur, MD, published on June 18, by Vituity, Dr. Kaur recommends that COVID-19 patients be kept at home whenever possible. The article provides details about how the “hospital at home” model has worked in a health system in California.


The questions of whether practitioners are a significant vector of transmission and if so, how to disrupt transmission will undoubtedly be resolved at some point in the future. In the meanwhile, practitioners must be vigilant about their conduct both on and off the job to help ensure that patients are not harmed. It’s “all hands on deck” all of the time!


The importance of vigilance, both at work and in personal life, is underscored by a recent article in The Boston Herald on July 29, 2020. The article reported that thirteen patients and twenty-three employees at a Massachusetts hospital, Baystate Medical Center, tested positive for the coronavirus after an employee recently traveled to an out-of-state virus “hot spot.” The situation was almost certainly exacerbated by the fact that hospital staff members gathered in break rooms without wearing masks or observing social distancing protocols.


Practitioners must be vigilant about their behavior at all times until more is known about how the coronavirus is transmitted, or until there is an available vaccine or treatment or both. In other words, it’s not enough to wear personal protective equipment (PPE) and to adhere to infectious disease protocols at work in order to prevent harm to patients and colleagues. The current pandemic calls for more. Practitioners’ conduct on and off the job may now cause harm to both patients and others. Be vigilant everywhere!



©2020 Elizabeth E. Hogue, Esq.  All rights reserved.

Read More
Southern Web SupportFirst, Do No Harm

Practical Reasons to Develop and Maintain Fraud and Abuse Compliance Programs

Providers may have heard or read about the importance of Fraud and Abuse Compliance Programs in their organizations. Despite the wealth of available information about Compliance Programs, many providers continue to express uncertainty about their value. The practical value of Compliance Programs is now clear.

Providers may avoid indictment and enforcement action, including Corporate Integrity Agreements (CIAs), if they are able to show that they have a commitment to Compliance Programs. The OIG often requires CIA’s that include a process for stringent monitoring by the OIG on a continuous basis. These monitoring activities can be extremely burdensome to providers in terms of both time and money. Providers with valid Compliance Programs may not be asked to develop and implement CIA’s.

Representatives of the U.S. Department of Justice are now asking for specific information about Compliance Programs, including how much money has been spent on them. Therefore, now is the time to develop or update Programs!

Here are some FAQs about Compliance Programs:

Why should we have a Fraud and Abuse Compliance Program?

First, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services has clearly stated that, consistent with the Affordable Care Act (ACA) all providers must have current Compliance Programs that are fully implemented.

Technically speaking, the Federal Sentencing Guidelines make it clear that establishment and implementation of Compliance Programs is considered to be a mitigating factor. That is, if accusations of criminal conduct are made, the consequences may be substantially less severe as a result of a properly implemented Compliance Program.

In addition, providers with Compliance Programs are more likely to avoid fraud and abuse. This is because Programs routinely establish an obligation on the part of every employee to report possible instances of fraud and abuse. This means that providers get the “first crack” to address areas of non-compliance!

Compliance Programs may also help to prevent qui tam or so-called “whistleblower” lawsuits by private individuals, rather than by government enforcers, who believe that they have identified instances of fraud and abuse. There are significant incentives to bring these legal actions since whistleblowers receive a share of monies recovered as a result of their efforts. Some whistleblowers have received millions of dollars. Compliance Programs make it clear that employees have an obligation to bring any potential fraud and abuse issues to the attention of their employers first.

In addition, the federal Affordable Care Act (ACA) requires providers to have Compliance Programs. In short, it’s the law!

Finally, the Deficit Reduction Act (DRA) requires providers who receive more than $5 million in monies from state Medicaid Programs per year to implement policies and procedures, provide education to employees and put information in their employee handbooks about fraud and abuse compliance. These requirements can be met through implementation of Fraud and Abuse Compliance Programs.

We don’t receive reimbursement from the Medicare or Medicaid Programs. Do we still need a Compliance Program?

Statutes and regulations governing fraud and abuse also apply to providers who receive payments from any federal and state healthcare programs, including Medicaid, Medicaid waiver and other federal and state health care programs, such as Tricare. Many private insurers have followed the federal government’s lead in terms of fraud and abuse enforcement, so private duty providers must have Compliance Programs, too.

We hear that the OIG of the U.S. Department for Health and Human Services has provided guidance for various segments of the healthcare industry regarding Compliance Programs. Specifically, the OIG has already published guidance for home health agencies, hospices and home medical equipment (HME) companies. Should we just use the model guidance that is applicable to us?

The answer is “no!” Guidance from the OIG is not a model Compliance Program. Guidance from the OIG consists of general guidelines and does not constitute a valid Compliance Program. In addition, the OIG has made it clear that Programs must be customized for each organization.

We have all sorts of policies and procedures in our organization. Why do we need something else called a Compliance Program?

Compliance Programs are specific types of documents that routinely address issues that providers do not usually cover in internal policies and procedures. In addition, providers may not gain benefits under the Federal Sentencing Guidelines, described in paragraph one above, if there is no formal document called a Compliance Program.

We just spent a lot of money to become accredited or reaccredited. Doesn’t certification mean that we are in compliance?

On the contrary, Compliance Programs appropriately address potential fraud and abuse issues. They also include mechanisms for helping to ensure compliance, such as processes for identification and correction of potential problems that are not addressed during the certification process. In other words, organizations may be accredited, but fail to meet applicable compliance standards for fraud and abuse.

Now is the time for all providers to recognize and act upon the need to establish and maintain Compliance Programs. “Working on it” is no longer good enough.

©2020 Elizabeth E. Hogue, Esq. All rights reserved.

Read More
Southern Web SupportPractical Reasons to Develop and Maintain Fraud and Abuse Compliance Programs

Provider Relief Funds: Potential Enforcement Action for False Claims

The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) announced a strategic plan for oversight of COVID-19 response and recovery on May 26, 2020. The Plan includes four goals:

  • Protect people
  • Protect funds
  • Protect infrastructure
  • Promote effectiveness

Providers who receive funds from the Provider Relief Fund are especially concerned about the OIG’s efforts to protect funds. The OIG has, of course, officially announced its intention to audit recipients of payments from the Fund. The terms and conditions of the Fund make it clear that full compliance is required. Non-compliance is grounds to recoup some or all of the payments made from the Fund. Therefore, failure to comply with all terms and conditions may result in repayment of the monies received.


Non-compliance with all terms and conditions may also result in allegations of false claims under the Federal False Claims Act. The False Claims Act includes these types of violations:




(1)       knowingly and willfully makes or causes to be made any false statement or a representation of a material fact in any application for any benefit or payment under this subchapter,


(2)       at any time knowingly and willfully makes or causes to be made any false statement or representation of material fact for use in determining rights to any such benefit or payment,


(3)       having knowledge of the occurrence of any event affecting (A) the initial or continued right to any payment, or (B) the initial or continued right to any such benefit or payment of any other individual in whose behalf he has applied for or is receiving such benefit or payment, conceals or fails to disclose such event with an intent fraudulently to secure such benefit or payment either in a greater amount or quantity than is due or when no such benefit or payment is authorized, or


(4)       having made application to receive any such benefit or payment for the use and benefit of another and having received it, knowingly and willfully converts such benefit or payment or any part thereof to a use other than for the use and benefit of such other person…”


The terms and conditions for receipt of funds include language that says that “any deliberate omission, misrepresentation, or falsification of any information contained in this Payment application or future reports may be punishable by criminal, civil, or administrative penalties.” Possible adverse action includes revocation of billing privileges in the Medicare Program and/or exclusion from all federal and state health care programs.


This statement certainly clarifies that the application for funds and subsequent reports filed may be treated as false claims under the False Claims Act.  Careful completion of all documents related to funds received is clearly important.



©2020 Elizabeth E. Hogue, Esq.  All rights reserved.

Read More
Southern Web SupportProvider Relief Funds: Potential Enforcement Action for False Claims

Wound Care: Legal Issues for Providers

Wound care is a risky business these days. Providers who render wound care services are at risk for:

  • Liability for negligent wound care
  • Violation of fraud and abuse prohibitions based on substandard wound care
  • Liability for abandonment when wound care services are discontinued
  • De-certification from participation in the Medicare/Medicaid Programs
  • Disciplinary action by state licensure boards with regard to individual practitioners who provide substandard wound care services
  • Indictment and prosecution for criminal neglect

Providers are at risk for these types of liability for a variety of reasons:

  • Standards of care are rapidly changing with regard to wound care. Many providers can remember the days when practitioners assumed that patients who were chronically ill would develop wounds. Now there are attorneys for patients and their families who would like to apply a standard of care that states that when patients develop wounds, it is due to providers’ negligence. This latter standard is certainly inappropriate if, for no other reason, than because it is not yet known with certainty what causes all wounds, what will work to heal wounds, and why some wounds heal and others do not. Nonetheless, when standards of care change rapidly, providers are always at increased risk.
  • Not all providers of wound care services have kept up with recent changes in standards of care. For example, according to the guidelines of the Agency for Health Care Policy and Research (AHCPR) and other national organizations, the routine application of Betadine is no longer an acceptable treatment for pressure ulcers. Yet practitioners still routinely receive orders from physicians to apply Betadine; a treatment that is clearly outside applicable standards of care.
  • Providers are at risk for wound care services because there has always been a “folk medicine” component to wound care. Many staff members have encountered orders for wound care that included shortening, liquid antacids, mixtures of sugar and water, and ointment intended for use on cows’ udders to prevent chafing when they are milked. A practitioner, for example, once described a wound as a “three-bear wound.” When asked about the meaning of this term, she explained that the doctor ordered staff to fill the patient’s wound with honey, and that it took three plastic bears worth of honey to do so! Hence, a “three-bear wound.” Despite some recent information about the possible benefits of Medihoney, treatment with honey bought in the grocery store is certainly contrary to national standards of care.
  • Finally, providers are at increased risk for wound care services because wounds look and smell terrible, especially to those who do not routinely encounter them; including patients, their families, judges, and jurors. From a practical point of view, it is hard for those unfamiliar with wounds to understand how patients could have such awful wounds unless someone has been negligent.

In view of the seriousness of these multiple risks, providers must be especially vigilant about managing risks related to wound care.



©2020 Elizabeth E. Hogue, Esq.  All rights reserved.

Read More
Southern Web SupportWound Care: Legal Issues for Providers

Court Refuses to Intervene in Medicare Payment Suspension

The U.S. District Court for the District of Missouri decided not to require the Centers for Medicare & Medicaid Services (CMS) to make a final determination on a provider’s suspension from the Medicare Program on the basis that such decisions are solely within the discretion of CMS

[Naushad v. United States Department of Health and Human Services, No. 4:20-CV-00018 JAR (E.D. Missouri May 29, 2020)]. Dr. Abdul Naushad owned a clinic called Advanced Pain Center (APC) that provided pain management services to Medicare beneficiaries. Dr. Naushad was charged with federal offenses related to illegal importation and use of a foreign injectable drug known as Orthovisc that was not approved by the U.S. Food and Drug Administration (FDA).


CMS suspended Medicare reimbursement to APC through its contractor, AdvanceMed, based on credible allegations of fraud. The Notice of Suspension advised APC that it had the right to submit a rebuttal statement. The Notice said that CMS would make a decision within fifteen days of receipt of the rebuttal about whether to lift the suspension. APC submitted a rebuttal statement asking CMS to lift the suspension. AdvanceMed responded two days later and said that it was reviewing the rebuttal statement and that a final response to the rebuttal “would be forthcoming.” APC then submitted a supplement to its original Rebuttal Statement.


APC also followed up six times with AdvanceMed regarding the status of its request, asking for status updates and demanding a final decision about lifting the suspension. AdvanceMed continued to respond by telling APC that it was reviewing the Rebuttal Statement and that a final response would be provided in addition to the interim response that was already provided. APC continued to submit letters and additional evidence to CMS and AdvanceMed to consider.


Approximately four months after payments were suspended, APC filed suit asking the Court to order CMS/AdvanceMed to provide a final decision about continuing the suspension of payments. The Court ruled against APC. According to the Court, APC is not entitled to a final determination about its suspension because CMS has no obligation to make any final determinations or lift suspensions before the investigation of providers is resolved, including any pending civil or criminal actions. Decisions to suspend payments or to continue payment suspensions, said the Court, are made at the sole discretion of CMS.


Further, the Court said that the length of suspensions is not limited to fifteen days. Suspensions based on credible allegations of fraud may last until the resolution of underlying investigations. Providers’ rights to appeal are triggered by overpayment determinations; not by decisions to continue or lift suspensions after consideration of rebuttal statements submitted by providers. The Court said that it would not upset the “balance” between hardship resulting from delays in administrative processes and the potential for overly casual or premature judicial intervention in administrative systems that process millions of claims every year.


There is definitely something wrong with this picture! Whether or not the allegations against providers are true, CMS “wins” because few providers have the financial resources to withstand suspension of payments from the Medicare Program for months at a time. The only option for many providers is to close their doors. Providers should surely receive more due process before such devastating losses take effect.



©2020 Elizabeth E. Hogue, Esq.  All rights reserved.

Read More
Southern Web SupportCourt Refuses to Intervene in Medicare Payment Suspension