La. Admin. Code tit. 50 § I-4177

Current through Register Vol. 50, No. 11, November 20, 2024

Section I-4177 - Withholding of Payments

A. The director of BHSF or his/her designee and the director of Program Integrity may initiate the withholding of a portion of or all payments or reimbursements to be made to a provider for the purpose of protecting the interest and fiscal integrity of the Medicaid Program if, during the course of claims review, the director of BHSF or his/her designee and the director of Program Integrity have a reasonable expectation:

1. that an overpayment to a provider may have occurred or may occur;

2. that a provider or provider-in-fact has failed to cooperate or attempted to delay or obstruct an investigation; or

3. has information that fraudulent, willful or abusive practices may have been used; or

4. that willful misrepresentations may have occurred.

B. Payments to the provider may be withheld if the director of BHSF or his/her designee and the director of Program Integrity has been informed in writing by a prosecuting authority that a provider or provider-in-fact:

1. has been formally charged or indicted for crimes; or

2. is being investigated for potential criminal activities which relate to the Medicaid Program or one or more of its programs or Medicare.

C. If the director of BHSF or his/her designee and the director of Program Integrity has been informed in writing by any governmental agency or authorized agent of a governmental agency that a provider or a provider-in-fact is being investigated by that governmental agency or its authorized agent for billing practices related to any government funded health care program, payment may be withheld.

D. Withholding of payments may occur without first notifying the provider.

E. Notice of Withholding

1. The provider shall be sent written notice of the withholding of payments within five working days of the actual withholding of the first check that is the subject of the withholding. The notice shall set forth in general terms the reason(s) for the action, but need not disclose any specific information concerning any ongoing investigations nor the source of the allegations. The notice must:

a. state that payments are being withheld;

b. state that the withholding is for a temporary period and cite the circumstances under which the withholding will be terminated;

c. specify to which type of Medicaid claims withholding is effective;

d. inform the provider of its right to submit written documentation for consideration and to whom to submit that documentation; and

e. inform the provider of its right to an administrative appeal.

2. Failure to provide timely notice of the withholding to the provider or provider-in-fact may be grounds for dismissing or overturning the withholding.

F. Duration of Withholding

1. All withholding of payment actions under this Chapter will be temporary and will not continue after:

a. the director of BHSF or his/her designee and the director of Program Integrity has determined that insufficient information exists to warrant the withholding of payments;

b. recoupment or recovery of overpayments has been imposed on the provider;

c. the provider or provider-in-fact has posted a bond or other security deemed adequate to cover all past and future projected overpayments; and

d. the notice of the results of the informal hearing.

2. In no case shall withholding remain in effect past the issuance of the notice of the results of the informal hearing, unless the withholding is based on written notification by an outside agency that an active and ongoing criminal investigation is being conducted or that formal criminal charges have been brought. In that case, the withholding may continue for as long as the criminal investigation is active and ongoing or the criminal charges are still pending, unless adequate bond or other security has been posted with BHSF.

G. Amount of the Withholding

1. If the withholding of payment results from projected overpayments, then when determining the amount to be withheld, the ability of the provider to continue operations and the needs of the recipient serviced by the provider shall be taken into consideration by the director of BHSF and the director of Program Integrity. In the event that a recipient cannot receive needed goods, services or supplies from another source, arrangements shall be made to assure that the recipient can receive goods, supplies, and services. The burden is on the provider to demonstrate that absent that provider's ability to provide goods, supplies, or services to that recipient, the recipient could not receive needed goods, supplies, or services. Such showing must be made at the informal hearing.

2. The amount of the withholding shall be determined by the director of BHSF or his/her designee and the director of Program Integrity. The provider should be notified of the amount withheld every 90 days from the date of the issuing of the Notice of Withholding until the withholding is terminated or the results of the informal hearing are issued, whichever comes first.

La. Admin. Code tit. 50, § I-4177

Promulgated by the Department of Health and Hospitals, Office of the Secretary, Bureau of Health Services Financing, LR 25:1646 (September 1999), repromulgated LR 29:600 (April 2003), amended by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38: 2785 (November 2012).

AUTHORITY NOTE: Promulgated in accordance with R.S. 36:254, 46:437.4 and 46:437.1-46:440.3 (Medical Assistance Program Integrity Law).