New Payment Hold and Overpayment Procedures

The IG has updated its procedures for payment holds and overpayments to reflect new requirements under Senate Bill 207, 84th Regular Session, which took effect September 1, 2015. The IG is currently developing rules to address these new requirements.

A "payment hold" means the temporary denial of reimbursement under the Medicaid program for items or services furnished by a specified provider. The IG imposes this administrative sanction in order to compel the production of records or when the IG determines that a credible allegation of fraud exists.

For purposes of a payment hold, a “credible allegation of fraud” is an allegation of fraud that the IG verifies has indicia of reliability after reviewing all allegations, facts and evidence. In addition, the IG must determine that continuing to pay the provider would present an ongoing significant financial risk to the state and a threat to the integrity of the Medicaid program.

A payment hold takes effect immediately; however, the provider subject to a payment hold can request an expedited process to challenge the hold.