C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER B—MEDICARE PROGRAM › PART 405—FEDERAL HEALTH INSURANCE FOR THE AGED AND DISABLED › Subpart C—Suspension of Payment, Recovery of Overpayments, and Repayment of Scholarships and Loans

42 C.F.R. § 405.370

Definitions

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(a) For purposes of this subpart, the following definitions apply:

Credible allegation of fraud. A credible allegation of fraud is an allegation from any source, including but not limited to the following:

(1) Fraud hotline tips verified by further evidence

(2) Claims data mining.

(3) Patterns identified through provider audits, civil false claims cases, and law enforcement investigations. Allegations are considered to be credible when they have indicia of reliability.

Fraud hotline tip. A complaint or other communications that are submitted through a fraud reporting phone number or a website intended for the same purpose, such as the Federal Government's HHS OIG Hotline or a health plan's fraud hotline.

Medicare contractor. Unless the context otherwise requires, includes, but is not limited to the any of following:

(1) A fiscal intermediary.

(2) A carrier.

(3) Program safeguard contractor.

(4) Zone program integrity contractor.

(5) Part A/Part B Medicare administrative contractor.

Offset. The recovery by Medicare of a non-Medicare debt by reducing present or future Medicare payments and applying the amount withheld to the indebtedness. (Examples are Public Health Service debts or Medicaid debts recovered by CMS).

Recoupment. The recovery by Medicare of any outstanding Medicare debt by reducing present or future Medicare payments and applying the amount withheld to the indebtedness.

Resolution of an investigation. An investigation of credible allegations of fraud will be considered resolved when legal action is terminated by settlement, judgment, or dismissal, or when the case is closed or dropped because of insufficient evidence to support the allegations of fraud.

Suspension of payment. 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 exists, or until the resolution of an investigation of a credible allegation of fraud.

(b) For purposes of §§ 405.378 and 405.379, the following terms apply:

Appellant means the beneficiary, assignee or other person or entity that has filed and pursued an appeal concerning a particular initial determination. Designation as an appellant does not in itself convey standing to appeal the determination in question.

Fiscal intermediary means an organization that has entered into a contract with CMS in accordance with section 1816 of the Act and is authorized to make determinations and payments for Part A of title XVIII of the Act, and Part B provider services as specified in § 421.5(c) of this chapter.

Medicare Appeals Council means the council within the Departmental Appeals Board of the U.S. Department of Health and Human Services.

Medicare contractor, unless the context otherwise requires, includes, but is not limited to, a fiscal intermediary, carrier, recovery audit contractor, and Medicare administrative contractor.

Party means an individual or entity listed in § 405.906 that has standing to appeal an initial determination and/or a subsequent administrative appeal determination.

Qualified Independent Contractor (QIC) Qualified Independent Contractor (QIC) means an entity which contracts with the Secretary in accordance with section 1869 of the Act to perform reconsiderations under § 405.960 through § 405.978.

Remand means to vacate a lower level appeal decision, or a portion of the decision, and return the case, or a portion of the case, to that level for a new decision.

Vacate means to set aside a previous action.

[61 FR 63745, Dec. 2, 1996, as amended at 74 FR 47468, Sept. 16, 2009; 76 FR 5961, Feb. 2, 2011; 86 FR 6093, Jan. 19, 2021]
Notes of Decisions
Cited in 45 cases (7 in the last 5 years), 1980–2026 · leading case: United States v. Lahey Clinic Hospital, Inc.
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United States v. Lahey Clinic Hospital, Inc. (2005) ca1 · cites it 3× “” La-hey’s argument of implied repeal of § 1345 and displacement of common law rests entirely, not on the Medicare Act itself, but on a supposed conflict between suit to recover overpayment under § 1345 and an administrative remedial scheme for collection of overpayments, see 42…”
United States of America, Cross-Appellee v. John Canova (2005) ca2 “” 42 C.F.R. § 405.370 . The statutory and regulatory scheme governing the administration of Medicare authorizes carrier-initiated audits of providers, like the United Healthcare audit of Raytel, to protect against fraud and overpayment, see 42 U.”
Harry M. Kechijian v. Joseph A. Califano, Jr., Etc. (1980) ca1 · cites it 3× “42 C.F.R. § 405.370 (b). We do not believe that the withholding of plaintiff’s payments after February 1972, standing alone, compels the inference that defendants “suspended” the payments under the Act.”
Anghel v. Sebelius (2012) nyed · cites it 2× “” 42 C.F.R. § 405.370 . A “recoupment” is “[t]he recovery by Medicare of any outstanding Medicare debt by reducing present or future Medicare payments and applying the amount withheld to the indebtedness.”
Sahara Health Care, Inc. v. Alex Azar, II, Secreta (2020) ca5 “” 42 C.F.R. § 405.370 . Congress pro- hibited HHS from recouping payments during the first two stages of admin- istrative review.”
In Re the Southern Institute for Treatment & Evaluation, Inc. (1998) flsb · cites it 4× “See 42 C.F.R. §§ 405.370 , 405.371(a)(2) (1997).”
Nichole Medical Equipment & Supply, Inc. v. Tricenturion, Inc. (2012) ca3 “42 C.F.R. § 405.370 . 5 . In its simplest form, a durable medical equipment supplier provides items such as hospital beds, wheel chairs, etc.”
A1 Diabetes & Med. Supply v. Alex Azar II (2019) ca6 “See 42 C.F.R. §§ 405.370 (a), 405.371(a)(3). The statute contains a hardship exception.”
Klein v. Heckler (1985) ca9 · cites it 6× “The carriers asserted that they were proceeding under the regulations which authorize them to suspend payments, 42 C.F.R. §§ 405.370 -.373 (1982) (describing suspension procedure).”
In Re: Tlc Hospitals, Inc., a California Corporation, Debtor. Charles Sims v. United States Department of Health and Hum (2000) ca9 “The Medicare regulations supply their own definition of recoupment: “[t]he recovery by Medicare of any outstanding Medicare debt by reducing present or future Medicare payments and applying the amount withheld to the indebtedness.”
United States v. Consumer Health Services of America, Inc. And Roger Schlossberg, Trustee (1997) cadc “§§ 1395g(a), 1395x(v)(l)(A) (1994); 42 C.F.R. §§ 405.370 (a)(1), 405.373(a)(2), 413.”
Gurpreet Padda v. Xavier Becerra (2022) ca8 “” 42 C.F.R. § 405.370 (a). Thus, under recoupment, a provider does not directly repay Medicare.”
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