La. Admin. Code tit. 50 § I-4181

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

Section I-4181 - General Provisions

A. Basis for Suspension

1. The director of BHSF and the director of Program Integrity must suspend all Medicaid payments to a provider after it determines there is a credible allegation of fraud for which an investigation is pending under the Medicaid Program against a provider unless it has good cause to not suspend payments or to suspend payment only in part.

2. The director of BHSF and the director of Program Integrity may suspend payments without first notifying the provider of its intention to suspend such payments.

3. A provider is entitled to an administrative review of the suspension of payment.

B. Notice of Suspension

1. The director of BHSF and the director of Program Integrity must send notice of its suspension of Medicaid payments within the following timeframes:

a. five days of taking such action unless requested in writing by a law enforcement agency to temporarily withhold such notice; and

b. 30 days if requested by law enforcement in writing to delay sending such notice, which request for delay may be renewed in writing up to twice and in no event may exceed 90 days.

2. The notice must include or address all of the following:

a. Medicaid payments are being suspended in accordance with 42 CFR 455.23;

b. set forth the general allegations as to the nature of the suspension action, but need not disclose any specific information concerning an ongoing investigation;

c. state that the suspension is for a temporary period, and cite the circumstances under which the suspension will be terminated;

d. specify, when applicable, to which type(s) of Medicaid claims or business units of a provider suspension is effective;

e. inform the provider of the right to submit written evidence for consideration by the director of BHSF and the director of Program Integrity; and

f. inform the provider of their right to a administrative appeal.

C. Duration of Suspension

1. All suspension of payment actions under this Section will be temporary and will not continue after either of the following:

a. legal proceedings related to the provider's alleged fraud are completed; or

b. the director of BHSF and the director of Program Integrity or the prosecuting authorities determine that there is insufficient evidence of fraud by the provider.

D. Good Cause Not to Suspend Payments. The director of BHSF and the director of Program Integrity may find that good cause exists not to suspend payments, or not to continue a payment suspension previously imposed, to a provider against which there is an investigation of a credible allegation of fraud if any of the following are applicable.

1. Law enforcement officials have specifically requested that a payment suspension not be imposed because such a payment suspension may compromise or jeopardize an investigation.

2. Other available remedies implemented by BHSF or Program Integrity more effectively or quickly protect Medicaid funds.

3. The director of BHSF and the director of Program Integrity determine, based upon the submission of written evidence by the provider that is the subject of the payment suspension, that the suspension should be removed.

4. Recipient access to items or services would be jeopardized by a payment suspension because of either of the following:

a. a provider is the sole community physician or the sole source of essential specialized services in a community; or

b. a provider serves a large number of recipients within a HRSA-designated medically underserved area.

5. Law enforcement declines to certify that a matter continues to be under investigation.

6. The director of BHSF and the director of Program Integrity determine that payment suspension is not in the best interest of the Medicaid program.

E. Good Cause to Suspend Payment Only in Part. The director of BHSF and the director of Program Integrity may find that good cause exists to suspend payments in part, or to convert a payment suspension previously imposed in whole to one only in part, to a provider against which there is an investigation of a credible allegation of fraud if any of the following are applicable.

1. Recipient access to items or services would be jeopardized by a payment suspension because of either of the following:

a. a provider is the sole community physician or the sole source of essential specialized services in a community; or

b. a provider serves a large number of recipients within a HRSA-designated medically underserved area.

2. The director of BHSF and the director of Program Integrity determines, based upon the submission of written evidence by the provider that is the subject of a whole payment suspension, that such suspension should be imposed only in part.

3. The credible allegation of fraud focuses solely and definitively on only a specific type of claim or arises from only a specific business unit of a provider and the director of BHSF and the director of program integrity determine and document in writing that a payment suspension in part would effectively ensure that potentially fraudulent claims were not continuing to be paid.

4. Law enforcement declines to certify that a matter continues to be under investigation.

5. The director of BHSF and the director of Program Integrity determine that payment suspension only in part is in the best interest of the Medicaid Program.

La. Admin. Code tit. 50, § I-4181

Promulgated by the Department of Health and Hospitals, Bureau of Health Services Financing, LR 38: 2786 (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).