Suspension actions. While the number of suspension actions taken by ZPICs has steadily increased in recent years, Medicare providers should expect to see this number continue to grow. Under the Affordable Care Act (often informally referred to as the “Health Care Reform” Act), CMS’ suspension authority has greatly expanded.
Points to keep in mind include:
Historical use of “suspension” authority by CMS. Historically, CMS has been empowered to suspend payments to Medicare providers in three circumstances:
Fraud or willful misrepresentation;
An overpayment of an undetermined amount has been identified; or
Payments that have been made (or are scheduled to be made) may be incorrect. (42 C.F.R. §405.371(a)(1).
Under the ACA, CMS may now suspend payments based on a “credible allegation of fraud” unless there is “good cause” not to suspend payments. CMS may suspend a provider based on allegations from any source, including:
Fraud hotline complaints.
Claims data mining.
Law enforcement investigations.
Keep in mind that unlike a postpayment audit, there is no administrative appeals remedy if a provider is placed on prepayment review. In light of the average length of time we have seen, being placed on prepayment review can be devastating for a provider with a high Medicare patient workload.
Seeking judicial relief in a prepayment review is expensive and likely to fail.
Unfortunately, most attempts we are aware of to get a Federal Judge to intervene have not succeeded.
Moreover, it has the added headache of putting your practice’s problems in front of a Federal Asst. U.S. Attorney (only DOJ has independent litigation authority). Do you really want to have your problems reviewed at this level?
While there is no “quick” answer, through hard work you can get off of prepayment review. Working with your attorney and outside experts, you can systematically address the problems raised.