Medicaid Provider Suspension for Organized Fraud

Joint Budget Committee. The bill authorizes the department of health care policy and financing (state department) to suspend the enrollment of a medicaid and children's basic health plan (programs) provider only if the state department identifies that the provider is participating in an alleged and ongoing organized crime or organized fraud scheme (scheme) that impacts the programs and if the state department documents in writing that at least 3 of the following factors are met:

• The provider has been enrolled in the programs for less than 3 years;
• At least 3 providers are involved in the scheme;
• The collective billing amount identified in the scheme exceeds $1 million;
• The provider's billing indicates a pattern of abuse or noncompliance;
• The volume of claims or billing amount has increased at a significant rate and there is no other reasonable explanation for the increase;
• The federal centers for medicare and medicaid services has approved a provider enrollment moratorium for the provider type involved in the scheme; or
• The state department has notified law enforcement of the scheme.

The state department is required to notify the provider of the suspension in writing, including the reasons for the suspension.

The state department may suspend a provider's enrollment for an initial period of 6 months while the state department conducts a review of the scheme. After the state department's review is complete, the state department must reinstate the provider's enrollment if the department determines the provider did not engage in a scheme. If the state department's review cannot be completed during the initial 6-month period, the state department may extend the review period in additional 6-month increments if the state department documents in writing the necessity for extending the review.

(Note: This summary applies to the reengrossed version of this bill as introduced in the second house.)