Corporate Compliance

OIG report says suspected fraud causes most CMS payment suspensions

Compliance Monitor, November 10, 2010

The majority of providers that CMS suspended in 2007 and 2008 exhibited characteristics that suggested fraudulent behavior, according to a report issued by the Office of Inspector General (OIG).

The OIG analyzed 253 suspensions CMS issued in 2007 and 2008 to assess CMS’ process for approving and implementing Medicare payment suspensions. The OIG presented its findings in “Memorandum Report: The Use of Payment Suspensions to Prevent Inappropriate Medicare Payments.” The OIG found that 64% of suspended providers showed questionable billing patterns and 63% of the suspensions were supported by information from beneficiaries or other providers.

The OIG concludes that CMS used the suspensions issued 2007 and 2008 as a tool to fight fraud and abuse. The OIG stated that it hopes the information contained in the report will help CMS create regulations under the Patient Protection and Affordable Care Act. The Act states that a provider’s payments may be suspended based on a credible allegation of fraud, unless there is good cause not to suspend such payments. It also states that CMS must consult with OIG in determining whether a credible allegation of fraud exists.

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