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Medicaid Payment Suspensions for Credible Allegations of Fraud

Federal financial participation in Medicaid is not available for items or services furnished by an individual or entity when there is a credible allegation of fraud, unless “good cause” exists not to suspend payment (SSA § 1903(i)(2), as amended by the ACA § 6402(h)(2)). When a State Medicaid agency determines that a credible allegation of fraud exists, the agency must suspend all or part of the Medicaid payments to the provider, while law enforcement investigates and potentially prosecutes the provider, unless good cause exists not to suspend payment (42 CFR § 455.23(a)). The State Medicaid agency must also refer the credible allegation of fraud for investigation to the State’s MFCU or to other appropriate law enforcement agencies in States with no certified MFCUs (42 CFR § 455.23(d)). We will review States’ use of payment suspensions as a program integrity tool.

Announced or Revised Agency Title Component Report Number(s) Expected Issue Date (FY)
Nov-16 Centers for Medicare & Medicaid Services Medicaid Payment Suspensions for Credible Allegations of Fraud Office of Audit Services and Office of Evaluation and Inspections OEI-09-14-00020 2017

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