[Code of Federal Regulations]

[Title 42, Volume 2]

[Revised as of October 1, 2005]

From the U.S. Government Printing Office via GPO Access

[CITE: 42CFR405.372]



[Page 93-94]

 

                         TITLE 42--PUBLIC HEALTH

 

                    CHAPTER IV--CENTERS FOR MEDICARE

                          & MEDICAID SERVICES,

                        DEPARTMENT OF HEALTH AND

                             HUMAN SERVICES

 

PART 405_FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED--Table of 

Contents

 

Subpart C_Suspension of Payment, Recovery of Overpayments, and Repayment 

                        of Scholarships and Loans

 

Sec. 405.372  Proceeding for suspension of payment.



    (a) Notice of intention to suspend--(1) General rule. Except as 

provided in paragraphs (a)(2) through (a)(4) of this section, if the 

intermediary, carrier, or CMS has determined that a suspension of 

payments under Sec. 405.371(a)(1) should be put into effect, the 

intermediary or carrier must notify the provider or supplier of the 

intention to suspend payments, in whole or in part, and the reasons for 

making the suspension.

    (2) Failure to furnish information. The notice requirement of 

paragraph (a)(1) of this section does not apply if the intermediary or 

carrier suspends payments to a provider or supplier in accordance with 

section 1815(a) or section 1833(e) of the Act, respectively, because the 

provider or supplier has failed to submit information requested by the 

intermediary or carrier that is needed to determine the amounts due the 

provider or supplier. (See Sec. 405.371(c) concerning failure to file 

timely acceptable cost reports.)

    (3) Harm to Trust Funds. A suspension of payment may be imposed 

without prior notice if CMS, the intermediary, or carrier determines 

that the Medicare Trust Funds would be harmed by giving prior notice. 

CMS may base its determination on an intermediary's or carrier's belief 

that giving prior notice would hinder the possibility of recovering the 

money.

    (4) Fraud or misrepresentation. If the intended suspension of 

payment involves suspected fraud or misrepresentation, CMS determines 

whether to impose the suspension and if prior notice is appropriate. CMS 

directs the intermediary or carrier as to the timing and content of the 

notification to the provider or supplier. CMS is the real party in 

interest and is responsible for the decision. CMS may base its decision 

on information from the intermediary, carrier, law enforcement agencies, 

or other sources. CMS determines whether the information is reliable.

    (b) Rebuttal--(1) If prior notice is required. If prior notice is 

required under paragraph (a) of this section, the intermediary or 

carrier must give the provider or supplier an opportunity for rebuttal 

in accordance with Sec. 405.374. If a rebuttal statement is received 

within the specified time period, the suspension of payment goes into 

effect on the date stated in the notice, and the procedures and 

provisions set forth in Sec. 405.375 apply. If by the end of the period 

specified in the notice no statement has been received, the suspension 

goes into effect automatically, and the procedures set forth in 

paragraph (c) of this section are followed.

    (2) If prior notice is not required. If, under the provisions of 

paragraphs (a)(2) through (a)(4) of this section, a suspension of 

payment is put into effect without prior notice to the provider or 

supplier, the intermediary or carrier must, once the suspension is in 

effect, give the provider or supplier an opportunity to submit a 

rebuttal statement as to why the suspension should be removed.

    (c) Subsequent action. If a suspension of payment is put into 

effect, the intermediary, carrier, or CMS takes timely action after the 

suspension to obtain the additional evidence it may need to make a 

determination as to whether an overpayment exists or the payments may be 

made. The intermediary, carrier, or CMS makes all reasonable efforts to 

expedite the determination. As soon as the determination is made, the 

intermediary or carrier informs the provider or supplier and, if 

appropriate, the suspension is rescinded or any existing recoupment or 

offset is adjusted to take into account the determination.

    (d) Duration of suspension of payment--(1) General rule. Except as 

provided in paragraphs (d)(2) and (d)(3) of this section, a suspension 

of payment is limited to 180 days, starting with the date the suspension 

begins.

    (2) 180-day extension. (i) An intermediary, a carrier, or, in cases 

of fraud and misrepresentation, OIG or a law enforcement agency, may 

request a one-time only extension of the suspension period for up to 180 

additional days if it is unable to complete its examination of the 

information or investigation, as appropriate, within the 180-



[[Page 94]]



day time limit. The request must be submitted in writing to CMS.

    (ii) Upon receipt of a request for an extension, CMS notifies the 

provider or supplier of the requested extension. CMS then either extends 

the suspension of payment for up to an additional 180 days or determines 

that the suspended payments are to be released to the provider or 

supplier.

    (3) Exceptions to the time limits. (i) The time limits specified in 

paragraphs (d)(1) and (d)(2) of this section do not apply if the case 

has been referred to, and is being considered by, the OIG for 

administrative action (for example, civil money penalties).

    (ii) CMS may grant an extension in addition to the extension 

provided under paragraph (d)(2) of this section if the Department of 

Justice submits a written request to CMS that the suspension of payment 

be continued based on the ongoing investigation and anticipated filing 

of criminal and/or civil actions. At a minimum, the request must include 

the following:

    (A) Identification of the entity under suspension.

    (B) The amount of time needed for continued suspension in order to 

implement the criminal and/or civil proceedings.

    (C) A statement of why and/or how criminal and/or civil actions may 

be affected if the requested extension is not granted.

    (e) Disposition of suspended payments. Payments suspended under the 

authority of Sec. 405.371(b) are first applied to reduce or eliminate 

any overpayments determined by the intermediary, carrier, or CMS, 

including any interest assessed under the provisions of Sec. 405.378, 

and then applied to reduce any other obligation to CMS or to HHS. In the 

absence of a legal requirement that the excess be paid to another 

entity, the excess is released to the provider or supplier.



[61 FR 63746, Dec. 2, 1996]