Findings

Congress finds the following: (1) In 2020, 139,000,000 individuals received health care coverage through the Medicare or Medicaid programs, costing the Federal Government approximately $1,500,000,000,000. Of these funds paid by United States taxpayers, $3,100,000,000 were discovered to have been fraudulent claims. (2) Ensuring the integrity of the Medicare and Medicaid programs is crucial to preventing fraud, waste, and abuse and safeguarding the financial sustainability of these important programs. (3) Even though the Centers for Medicare & Medicaid Services (CMS) utilization of Unified Program Integrity Contractors (UPICs) has shown to be effective at identifying bad actors defrauding the Federal Government through the Medicare and Medicaid programs, current Federal law and regulations have shown to be harmful to most providers who are submitting Medicare and Medicaid claims in good faith. (4) Existing law provides CMS and UPICs broad authority and discretion to suspend Medicare payments for up to a year pending the investigation of credible allegations of fraud. (5) However, current law does not require adequate transparency from CMS or UPICs into the nature of the alleged fraud before Medicare payments are suspended. Current law also does not require CMS or UPICs to provide adequate due process to providers whose payments have been suspended to challenge or cure the allegations of fraud prior to the suspension of Medicare payments. (6) In addition, anecdotal reports have shown that some UPICs extend the suspension of Medicare payments on a routine basis so that they may have additional time to finish their audit despite not providing evidence that the continuation of a payment suspension is necessary to protect the integrity of the Medicare program. (7) The broad authority to suspend Medicare payments pending the investigation of a credible allegation of fraud without adequate due process or transparency places the financial viability of many Medicare providers acting in good faith at risk. (8) If Medicare providers acting in good faith close their doors as a result of the unnecessary suspension of payments by CMS or UPICs, Medicare beneficiaries and the American public could face additional barriers to access to necessary health care services as a direct result of unfair Federal law and regulations.