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Michael Petruzzelli

, National Council for Mental Wellbeing

Providers to Get Due Process Protections for Alleged Fraud in New Bill

March 24, 2016 | Medicaid | Comments
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A new bill in Congress establishes due process protections in Medicaid for health care providers in cases of alleged fraud. The Medicaid Program Integrity Enhancement Act (S. 2701/H.R. 4802) – introduced by Senator Martin Heinrich (D-NM) and Representative Ben Lujan (D-NM) – has been a priority for the National Council since 2012, after a group of New Mexico behavioral health clinics were forced to close their doors when the state Medicaid agency suspended all payments to the clinics amid allegations of fraud. The shuttered clinics represented the majority of all community-based behavioral health safety net providers in New Mexico, leaving low-income residents with a crisis in access to lifesaving mental health and addiction care.

“Fraud and abuse in Medicaid must be taken very seriously. Yet, as the cases in New Mexico show, upstanding providers must be protected from unsubstantiated allegations,” said Linda Rosenberg, President and CEO of the National Council for Mental Wellbeing. “Just as in any part of our legal system, individuals and organizations deserve to know the allegations against them and to have those allegations investigated and resolved in a speedy manner so that we can prevent future crises like that seen in New Mexico.”

The bill requires states to examine the impact that suspending payments would have on beneficiary access as well as to provide information to clinics and other providers on the nature of the allegations against them. It also establishes a process by which clinics could appeal states’ decisions to suspend payments. Some states already have legal protections in place similar to those outlined in the new legislation.  However, such protections are not required under current federal regulations, leaving many providers at risk for unfounded allegations of fraud.

The National Council lauded the bill’s inclusion of a requirement that states consider the effect on beneficiary access to care before taking action to suspend providers’ Medicaid payments. “In the New Mexico case, patients’ access to care evaporated practically overnight,” said Rosenberg. “This is especially galling because at the end of an unreasonably protracted investigation, the providers were found to have done no wrong. State Medicaid agencies must carefully consider how their decisions affect patients who rely on these services every day. We thank Senator Heinrich and Representative Lujan for introducing this important legislation.”