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Wednesday, August 22, 2012

Amended Regulations to the Patient Protection and Affordable Care Act

Effective August 22, 2012, the Office of Medicaid Inspector General (“OMIG”) amended its regulations (Sections 518.7 and 518.9 of Title 18) to implement sections of the Patient Protection and Affordable Care Act (“ACA”), to require the state to withhold payments to medical assistance (Medicaid) program providers after the agency determines or is notified that a “credible allegation” of fraud exists involving the provider and for which there is a pending investigation. In both instances, untested and unproven allegations of fraud are enough to justify the withholding of payment for services rendered, and the burden is effectively shifted to the physician or provider to rebut these allegations in order to put a freeze to the ongoing recoupment efforts – all while the underlying investigation remains underway.  Since fraud is certainly in the eye of the beholder in these types of circumstances, a certain amount of discretion exists to further complicate this financially disruptive situation.

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