What Happens to a Payment Suspension After Eighteen Months?
CMS issued Transmittal 14002 on Monday with a summary insisting it does not affect providers and needs no provider education. It revises one section of the Program Integrity Manual, and the red italics tell the fraud contractors to stop sending resolution letters once a case or payment suspension is three years old. The suspension regulation says good cause to end one must be deemed to exist at eighteen months. Here is the diff, that clock priced per $100,000 of monthly Medicare cash, and the enforcement volume that built the backlog behind it.
CMS posted a manual revision to its transmittals page at 12:58pm Monday with a summary that goes out of its way to tell you it is none of your business.
"These updates do not affect the provider and/or beneficiary populations," it reads. "Rather, these updates are solely related to contractor technical processes and procedures."
Section IV of the change request: Provider Education: None. Impacted contractors: None.
Transmittal 14002 revises exactly one section of the Program Integrity Manual, section 4.5.1, and the red italics are about who gets a letter in the mail. They are also the first place CMS has written down what it thinks a payment suspension's shelf life is.
"How long does Medicare expect to hold the money?"
What the Red Italics Actually Say
We pulled the live Chapter 4 PDF, which CMS last rebuilt on September 9 and has not yet overwritten, so it is still the before copy.
Section 4.5.1 in that copy carries a revision stamp of 13821, issued June 9. The new one carries 14002, issued October 26, 139 days later.
Diff them and exactly two things moved. Everything else in the section is byte-identical, including the 45 business days a MAC gets to screen and forward a complaint, the 15 calendar days a UPIC gets to acknowledge it, the 7 calendar days it gets to send a resolution letter once the investigation closes, and the I-MEDIC's own 5, 30 and 45-day clocks.
The two changes:
- Three new paragraphs on the letter. UPICs and the I-MEDIC "are not expected to send resolution letter(s) to the beneficiary/complainant" when two conditions hold together: the case or payment suspension is three years or older, and it is tied to a "large-scale law enforcement investigation resulting in takedowns." Where a case is younger than three years but the contractor is sitting on "a high number of pending resolution letters," it asks its Business Function Lead whether to send them. Either way the non-sending gets documented in the closing summary, citing the manual section itself as the basis.
- One phrase on the filing. Complaints a UPIC bounces back to the MAC used to be tracked "in the UPIC's internal tracking system." They are now tracked in the Unified Case Management system, which belongs to CMS rather than to the contractor.
That second one is requirement 14654.2, and it is the only line in the change request that moves a record off a contractor's shelf and onto CMS's.
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