Updated on: June 22, 2012

OIG: Majority of CMS-Suspended Part B Providers Exhibited Characteristics Suggesting Fraud in 2007-08

Original story posted on: November 3, 2010

cbuck120dsIn a memorandum this week to The Centers for Medicare & Medicaid Services, the Office of Inspector General reports that of the 253 Part B providers suspended in 2007 and 2008, a "great majority" exhibited what the agency described as "characteristics that suggest of fraud."


CMS may suspend payments to a Medicare provider or supplier for any of three circumstances: 1) fraud or willful misrepresentation, 2) when an overpayment exists but the amount has not been determined, or 3) when payments made or pending may be incorrect. CMS also may suspend payments based on requests from its contractors or from law enforcement, the OIG noted.


The OIG reported that it analyzed 253 suspensions CMS imposed in 2007 and 2008. Part B providers composed 85 percent of those suspensions. Overpayments to providers in those years totaled at least $206 million.


According to the OIG, 74 percent of suspended providers showed questionable billing patterns. Sixty-three percent of suspensions were supported by information from beneficiaries or from other providers; this information included evidence that the suspended providers had billed for services that never were received or were medically unnecessary and had used other providers' billing numbers to seek payment for items or services that had not been authorized.


Twenty-four percent of suspended providers billed Medicare before their suspensions despite having vacant physical locations.


The OIG noted that payment suspensions were used in 2007 and 2008 almost exclusively as a tool to fight fraud. Recognizing that the Patient Protection and Affordable Care Act was signed into law, the OIG reminded that the law 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.
Chuck Buck

Chuck Buck is the publisher of RACmonitor and is the program host and executive producer of Monitor Monday.

This email address is being protected from spambots. You need JavaScript enabled to view it.