Pennsylvania Compiled With the Requirements of the Affordable Care Act in Its Review of Cases of Credible Allegations of Medicaid Fraud

摘要

The Affordable Care Act requires States to suspend Medicaid payments to providers when they receive a credible allegation that the pro viders have submitted fraudulent claims. This review of Pennsylvania's adjudication of such allegations is part of the Office of Inspector General's oversight of the Affordable Care Act. The objective was to determine whether Pennsylvania's Department of Public Welfare (State agency) complied with the requirements of the Affordable Care Act when it received a credible allegation of fraud by its Medicaid providers. Requirements for Cases With Credible Allegations of Fraud The Medicaid program provides medical assistance to low-income individuals and individuals with disabilities (Title XIX of the Social Security Act (the Act)). The Affordable Care Act amended the Act to strengthen payment safeguards over potentially fraudulent claims. Under the Act, States that do not suspend payments to providers when investigation of a credible allegation of fraud is pending are not eligible for Federal matching funds for payments to those providers unless the State shows that it has good cause not to suspend such payment. A State may find that good cause not to suspend payments exists if, for example, law enforcement officials request that a payment suspension not be imposed or if other remedies more effectively or quickly protect Medicaid funds.