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Suspicion of Medicare Fraud Triggers Most Reimbursement Suspensions

Cheryl Clark, for HealthLeaders Media, November 3, 2010

For example, payment for services not considered durable medical equipment amounted to 80% in 2007 but only 22% in 2008. Part A suspended payments, generally for inpatient hospital care, went from 6% of the total suspended payments in 2007 to 32% of total suspended payments in 2008.

Under current rules, CMS can suspend payments to a Medicare provider under three circumstances: 1) fraud or willful misrepresentation, 2) when an overpayment exists but the amount has been determined and 3) when payments made or to be made may be incorrect.

Other findings from the report include:

  • Of the requests from Medicare contractors that a provider be suspended from receiving payment, nearly one-fourth were approved the same day, but 27% took between three and seven days and 29% took longer, as many as 92 days.
  • Of the 253 suspended providers, only 41 submitted rebuttals. The suspensions can not be appealed, but CMS removed suspensions for three.
  • For those suspensions that have been lifted, the average length was 267 days but for Part A providers it was 179 days and for Part B providers, 341.

Cheryl Clark is senior quality editor and California correspondent for HealthLeaders Media. She is a member of the Association of Health Care Journalists.
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