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CMS Letter to Sheila Jackson Lee

CMS Letter to Sheila Jackson Lee

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Published by T.L. Langford
This letter from the Centers for Medicare and Medicaid Services is in response to Congresswoman Sheila Jackson Lee's June 18 request that that Riverside General Hospital's Medicare payments be restored. The hospital is under investigation by the FBI and the federal Department of Health and Human Services Office of Inspector General.
This letter from the Centers for Medicare and Medicaid Services is in response to Congresswoman Sheila Jackson Lee's June 18 request that that Riverside General Hospital's Medicare payments be restored. The hospital is under investigation by the FBI and the federal Department of Health and Human Services Office of Inspector General.

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Published by: T.L. Langford on Jul 20, 2012
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03/06/2015

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DEPARTMENT
OF
HEALTH
&
HUMAN
SERVICES
The Honorable Sheila Jackson LeeHouse
of
RepresentativesWashington, DC 20515Dear Representative Jackson Lee:
Centers for Medicare
&
Medicaid Services7500 Security BoulevardBaltimore, MD 21244-1850
Thank you for your letter requesting that the payment suspension
of
Riverside GeneralHospital's ("Riverside") Medicare payments be removed based on the "good cause" exceptionsfound in 42 C.F.R.
§
405.371(b). In this, as in all payment suspension matters, the Centers forMedicare and Medicaid Services ("CMS") is acutely aware
of
the difficulties that suchadministrative actions can pose for providers such as Riverside, and so we take ourresponsibilities in this regard extremely seriously.CMS authorized the June 8, 2012 suspension
of
Riverside's Medicare payments based oncredible allegations
of
fraud.
See
42 C.F.R.
§
405.371(a)(2). Where a provider has beensuspended based on credible allegations
of
fraud, CMS may find that good cause exists not tocontinue to suspend payments.
See
42 C.F.R. § 405.371(b). Please note that paymentsuspensions can be used to recoup past overpayments, so the continuation
of
a paymentsuspension does not necessarily mean that a provider's current claims are suspect. Thus, when aprovider has in the past committed acts that constitute credible allegations
of
fraud, as occurredhere, even
if
the provider has reformed its ways, often the best way to protect the Medicareprogram and return potentially fraudulently paid dollars to the Medicare Trust Funds is to imposea payment suspension against current payments.In this case, while it is admirable that Riverside reports that it has completely cut ties with anindividual who has been accused
of
egregious fraud, that does not necessarily change the factthat Riverside received large improper payments when that individual still worked at Riverside.As you know, in this case the alleged fraud may have cost U.S. taxpayers many millions
of
dollars.When payment suspensions are at issue, CMS constantly needs to balance the legitimate needs
of
honest providers with the harm inflicted on the Medicare Trust Funds and U.S. taxpayers. Theseare often difficult judgments to make. In this instance, given the extremely strong evidence
of
alarge fraud, the balance favors protecting the Program and the taxpayers by means
of
a paymentsuspension. You should understand that under CMS rules, this payment suspension is only atemporary measure, and will be terminated as soon as the investigation is concluded, and anoverpayment (or, in rare cases, an underpayment) is determined.

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