Sec. 3. Part D suspension of claims payment

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Amend 1860D–12(b)(4) of the Social Security Act ( 42 U.S.C. 1395w–112(b)(4) ) is amended by adding at the end the following new subparagraph: A PDP sponsor may suspend payments and clean claim notifications to a pharmacy pending an investigation of a credible allegation of fraud (as defined in clause (ii)) against the pharmacy, unless the Secretary determines there is a good cause not to suspend payments. In this subparagraph, the term credible allegation of fraud includes— a complaint made on the Medicare fraud hotline; detection of potential fraud through the analysis of claims data; detection of potential fraud through identification of inappropriate dispensing through audits, civil false claims cases, and law enforcement investigations; and claims referred to Medicare drug integrity contractors (MEDICs).

Nothing in this subparagraph shall be construed as limited the authority of a PDP sponsor to conduct post-claim payment review. .

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42 USC 1395w–112(b)(4)

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Sec. 3

Part D suspension of claims payment

Cite42 USC 1395w–112(b)(4)

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