Current through Register Vol. 48, No. 38, September 20, 2024
a) Effective July 1, 2012, the Department may
withhold payments, in whole or in part, to a provider or alternate payee upon:
1) initiation of an audit;
2) quality of care review;
3) investigation in which there is a credible
allegation of fraud; or
4) the
provider or alternate payee is demonstrating a clear failure to cooperate with
the Department, giving rise to the need for a withholding of
payments.
b) The
Department may withhold payments without first notifying the provider or
alternate payee of its intention to withhold payments.
c) A provider or alternate payee may request
a hearing or a reconsideration of payment withholding, and the Department must
grant the request.
d) The
Department must send notice of its withholding of payments within five days
after taking the action. The notice shall:
1)
Set forth the general allegation as to the nature of the withholding action;
however, the notice need not disclose any specific information concerning an
ongoing investigation.
2) State
that payments are being withheld in accordance with Section 12-4.25(K-5) of the
Code.
3) State that the withholding
is for a temporary period, as specified in subsection (g), and cite the
circumstances under which withholding will be terminated.
4) Specify, when appropriate, which type or
types of claims are withheld.
5)
Inform the provider or alternate payee of the right to request a hearing or a
reconsideration of the withholding by the Department, including the ability to
submit written evidence.
6) Inform
the provider or alternate payee that a written request may be made to the
Department for a hearing or reconsideration for the full or partial release of
withheld payments and that such requests may be made at any time after the
Department first withholds payments.
e) A provider or alternate payee may request
reconsideration of payment withholding for the purpose of a full or partial
release of payments withheld pursuant to Section 12-4.25(K-5) of the Code. The
provider or alternate payee shall submit a written request for reconsideration
and the reasons for the reconsideration to the Department's Inspector General
at:
Office of Inspector General
404 North Fifth Street
Springfield, Illinois 62706
Or by e-mail to: HFS.OIGWebmaster@illinois.gov.
1) The request may include documentation to
contest a credible allegation of fraud or failure to cooperate with the
Department.
2) Partial or full
release of payments on pending and subsequently submitted bills may be granted,
at the discretion of the Inspector General, when it is in the best interest of
Medical Assistance Program recipients. Factors in this decision may include,
but are not limited to, recipients' access to medical services or the potential
transport of patients from long term care settings.
f) A provider or alternate payee may request
a hearing on the issue of a withholding of payments pursuant to Section
12-4.25(K-5) of the Code. The only issue at hearing will be whether a partial
or full release of funds is properly based on the following factors:
1) Whether there is a credible allegation of
fraud;
2) Whether the provider or
alternate payee demonstrated a clear failure to cooperate with the Department,
giving rise to the need for a withholding of payments;
3) Whether a release is in the best interest
of the recipients of medical assistance based on access to medical services for
recipients; and
4) The potential
movement of patients from long term care settings.
g) All withholding of payment actions under
this Section shall be temporary and shall not continue after either of the
following:
1) The Department determines that
there is insufficient evidence of fraud, or the provider or alternate payee
demonstrates clear cooperation with the Department, as determined by the
Department, so that the circumstances do not give rise to the need for
withholding of payments; or
2) the
withholding of payments has lasted for a period in excess of three
years.
