CMS Medicaid Suspension Defense and Medicare Suspension Defense

We Defend Healthcare Providers that Are Facing Medicaid or Medicare Suspension Nationwide

As a healthcare provider, losing your ability to collect Medicaid or Medicare payments can have serious consequences. The Centers for Medicare and Medicaid Services (CMS) use various program integrity measures to assess Medicaid and Medicare billing compliance; and, when it uncovers evidence of suspected fraud, it can suspend payments to the provider involved.

We defend healthcare providers that are facing Medicaid or Medicare suspension nationwide. If your practice’s or business’s ability to collect Medicaid or Medicare funds is at risk, we can help—but it is important that you contact us promptly. CMS, its Unified Program Integrity Contractors (UPICs), and its other fee-for-service auditors use claims data mining and various other techniques to identify questionable billing patterns, and questionable patterns identified in providers’ billing data can lead to swift and high-risk enforcement.

How Healthcare Providers Can Lose Their Ability to Collect Medicaid or Medicare Payments

Several issues can put healthcare providers at risk of losing their ability to bill under the Medicaid or Medicare program. Provider audits target all forms of billing fraud, and law enforcement investigations can target all forms of billing fraud (in addition to other forms of health care fraud) as well. With this in mind, some examples of fraud allegations that can lead to an “all claims” or partial suspension for program-participating providers include:

• Billing for ineligible services provided to Medicaid or Medicare beneficiaries
• Billing for services not provided to Medicaid or Medicare patients (so-called “phantom billing”)
• Billing Medicaid or Medicare for services that lack medical necessity
• Submitting claims for services provided by an unlicensed member of a provider’s practice
• Providing services (and billing for services) without meeting the Medicaid or Medicare enrollment requirements
• Knowingly retaining improper payments from Medicaid or Medicare (ignoring the fact that an overpayment exists)
• Paying or receiving referral fees and other “kickbacks” paid out of a Medicaid or Medicare provider’s payments
• Making any willful misrepresentation to a Medicaid or Medicare contractor during an audit or otherwise attempting to cover up improper program billings
• When an overpayment exists, but a final overpayment amount has not yet been determined

Again, these are just examples. CMS can (and will) suspend Medicare payments or Medicaid payments for other reasons as well. If you are concerned about losing your ability to bill Medicare or Medicaid for any reason—or if you have received a suspension notice—we strongly encourage you to speak with one of our lawyers right away.

Defending Against Medicare or Medicaid Suspension

If your business’s or practice’s ability to bill Medicare or Medicaid is at risk, executing an effective defense strategy will be key to protecting its program eligibility going forward. Depending on the circumstances, this may involve:

Demonstrating Medicare or Medicaid Billing Compliance

If your business’s or practice’s program billings are compliant, you should not be at risk of facing a Medicaid or Medicare suspension from CMS. While claims data mining or other auditing or investigative techniques may suggest fraud, this does not necessarily mean that fraud has actually occurred.

There are several reasons why an individual provider’s billings may stand out under scrutiny, and many of these reasons have nothing to do with fraud. In this scenario, affirmatively demonstrating compliance—whether in a rebuttal statement or through other means—could be essential for avoiding unnecessary and unwarranted consequences.

Defending Against a Credible Allegation of Fraud

If you have received a demand letter or suspension notice and your business or practice is facing a credible allegation of fraud, dealing effectively with CMS, the U.S. Department of Health and Human Services Office of Inspector General (HHS OIG), or other federal authorities will require a very different approach. Along with Medicare and Medicaid suspensions, credible allegations of fraud can also lead to civil false claims cases (and criminal false claims cases in certain circumstances), and this is an extremely high-risk scenario that requires highly experienced counsel.

Relying on the Good Cause Exceptions Applicable to Medicare Suspensions

In some cases, another viable approach to defending against credible allegations of fraud will involve relying on the good cause exceptions that are applicable to Medicare suspensions. These exceptions include:

• “OIG or other law enforcement agency has specifically requested that a payment suspension not be imposed because such a payment suspension may compromise or jeopardize an investigation;
• “It is determined that beneficiary access to items or services would be so jeopardized by a payment suspension in whole or part as to cause a danger to life or health;
• “It is determined that other available remedies implemented by CMS or a Medicare contractor more effectively or quickly protect Medicare funds than would implementing a payment suspension;” and,
• “CMS determines that a payment suspension or a continuation of a payment suspension is not in the best interests of the Medicare program.”

When a provider’s ability to bill Medicare is at risk, it is imperative to: (i) consider all viable defense options; and, (ii) make informed decisions based on reliable information. Our lawyers can provide the advice and insights you need, and we can work with CMS contractors or federal authorities on your behalf to protect your business against administrative action (and against civil or criminal enforcement action if necessary).

What To Do if Your Are Facing Medicaid or Medicare Payment Suspension

With all of this in mind, if your business or practice is facing a Medicaid or Medicare payment suspension, what should you do? In this situation, some key steps to take include:

• Engage Experienced Counsel Promptly – Once you receive notice that your practice or business is at risk of facing a Medicare or Medicaid suspension, you should engage experienced counsel promptly. Again, this is a high-risk scenario that will require an informed, strategic, and proactive defense in order to avoid unnecessary consequences.
• Conduct an Internal Billing Compliance Assessment – Defending against allegations of Medicare or Medicaid billing fraud requires an in-depth understanding of your practice’s or business’s billing compliance history. If you can provide records that demonstrate compliance, this could help facilitate an efficient and favorable resolution. If you cannot provide records that demonstrate compliance, this is a very different scenario.
• Target a Favorable Resolution that Protects Your Ability to Bill Medicare and Medicaid – Even when facing substantiated allegations of fraud, many providers will still be able to protect their ability to bill Medicare and Medicaid. With that said, there are no guarantees, and at-risk providers should work with their counsel to specifically target a favorable resolution that preserves their program eligibility.

FAQs: Defending Against CMS Medicaid or Medicare Suspension

Schedule a Free Consultation with a CMS Suspension Defense Lawyer at Oberheiden P.C.

If your healthcare practice or business is facing a Medicare or Medicaid suspension, we strongly encourage you to contact us so that we can help. We represent Medicare and Medicaid providers nationwide. To speak with an experienced CMS suspension defense lawyer in confidence as soon as possible, call 888-680-1745 or tell us how we can help online now.