When Suspension of Payment May Be Used

8.3.1 – When Suspension of Payment May Be Used (Rev. 10228; Issued: 07-27-20; Effective: 08-27-20; Implementation: 08-27-20) A payment suspension may be used when there is: Reliable information that an overpayment exists, but the amount of the overpayment is not yet determined; Reliable information that the payments to be made may not be correct; Reliable information that the provider fails to furnish records and other essential information necessary to determine the amounts due to the provider; In cases of suspected fraud, a payment suspension may be used when there is a credible allegation of fraud. These above reasons for implementing a payment suspension are described more fully below. NOTE: If a payment suspension is approved, this edit of withholding of Medicare funds takes precedent over any other edits withholding money in the MAC systems. When it is time to terminate the payment suspension, the withheld funds must first be applied to the Medicare overpayment(s) and any excess is then applied to any other outstanding overpayments or debts owed to CMS or HHS in accordance with 42 CFR §405.372(e), unless otherwise directed by CMS. NOTE: For providers that file cost reports, a payment suspension may have little impact. If the provider is receiving periodic interim payments (PIP), the interim payments may be suspended. If the provider is not receiving PIPs, a payment suspension will affect the settlement of the cost report. When an overpayment is determined, the amount is not included in any settlement amount on the cost report. For example, if the A/B MAC (A) has withheld (suspended) $100,000 when the cost report is settled, the A/B MAC (A) would continue to hold the $100,000. This means that if the cost report shows the Medicare program owing the provider $150,000, the provider would only receive $50,000 until the payment suspension action has been terminated. If the provider owes the Medicare program money at settlement, the amount of the suspended payment would increase the amount owed by the provider. In most instances, A/B MACs (A) should adjust interim payments to reflect projected cost reductions. The contractors are to limit the adjustment to the percentage of potential fraud or the total payable amount for any other reasons. For example, if the potential fraud involved five percent of the periodic interim rate, the reduction in payment is not to exceed five percent. Occasionally, suspension of all interim payments may be appropriate. NOTE: If a payment suspension is approved for a home health agency, all Requests for Anticipated Payments (RAPs) are to be suppressed (disapproved) in accordance with 42 C.F.R. §409.43(c)(2). The UPIC shall make this request to CPI as part of its request for a payment suspension. In addition, CMS may suppress RAP payments for program integrity concerns absent a payment suspension. If the UPIC determines that a RAP suppression is appropriate they shall submit the following information to CMS: • Are final bills being submitted by the HHA? Yes or No • Indicate the volume (dollar and number of claims) of RAPs for the past 12 months. • A brief summary supporting the request for RAP suppression.