Payment Suspension – Moving Away from Pay and Chase

CMS now has the authority to suspend further payments to a provider following receipt of any “credible allegation of fraud.”  Allegations are deemed to be credible when they have an “indication of reliability.”  The allegation can come from a number of possible sources such as employee complaints, whistleblower claims, provider audits, false claims allegations, or virtually any other source as long as CMS deems the allegation to be credible.  The suspension of payment may last up to eighteen (18) months or longer if a referral is made for further administrative action.

Suspension of payment is an extremely draconic remedy which can threaten the financial existence of some providers.  The remedy is available even before there is solid proof that fraud has been committed.  The possibility of having payment suspended is yet another reason for providers of all types to adopt sensible, scaled compliance programs.  An effective compliance program is the provider’s best proactive defense to the potentially devastating impact of having payment suspended.