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 States 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