In a July 2, 2025, press release, the U.S. Department of Justice (DOJ) announced a new “DOJ-HHS False Claims Act Working Group” (the Working Group) and identified multiple priority enforcement efforts for the Working Group to address health care fraud and abuse. (The press release also encourages the submission of tips and complaints on waste and mismanagement.) Membership in the Working Group will include leadership from the U.S. Department of Health and Human Services (HHS) Office of General Counsel, the Centers for Medicare & Medicaid Services (CMS) Center for Program Integrity, the Office of Counsel to the HHS Office of Inspector General (OIG), and DOJ’s Civil Division.
As pertinent to this discussion, DOJ’s press release noted that as part of its efforts to address cases, the Working Group “shall discuss considerations bearing on whether HHS should implement a payment suspension pursuant to 42 C. F.R. § 405.370….” Although CMS has several bases upon which it can impose payment suspensions, including “reliable information that an overpayment exists,” 42 C.F.R. § 405.371, its quickest and most deadly tool in the suspension arsenal is a suspension based on a “credible allegation of fraud.”
As defined by 42 C.F.R. § 405.370, a Medicare payment suspension is the withholding of payment by a Medicare contractor from a provider or supplier of an approved Medicare payment amount before a determination of the amount of the overpayment...
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