Due process is not an obstacle to program integrity; it is part of what makes enforcement legitimate and accurate. In Goldberg v. Kelly, the U.S. Supreme Court held that people receiving public assistance are entitled to an evidentiary hearing before benefits are terminated. The Court described timely and adequate notice detailing the reasons, an opportunity to be heard and present evidence, the chance to confront adverse witnesses, an impartial decision-maker who was not involved in the original decision, and a decision that states its reasons and the evidence relied on. These ideas shape how public programs treat people today.
For people who receive Medicaid, federal fair hearing rules at 42 CFR part 431, subpart E, spell out protections. Notices must state the intended action and its effective date, the specific reasons, the rules that support it, the right to a hearing and the circumstances in which services continue during an appeal. Agencies generally must send notice at least ten days before the action, with limited exceptions, including a shorter period when there are facts indicating probable fraud by the recipient. When a person requests a hearing in time, services generally continue until the hearing decision. Program integrity actions that affect people's eligibility or services must follow these rules, and the state's appeals office decides the hearing.
Providers have protections too. Under 42 CFR 455.23, a state Medicaid agency must suspend payments to a provider after determining there is a credible allegation of fraud, unless it finds good cause not to. The agency must send notice within a short time frame, generally five days, unless law enforcement asks for a delay. The notice must say payments are suspended, describe the general allegations without disclosing investigative details, explain that the suspension is temporary, identify the affected claims or business units, tell the provider it may submit written evidence and describe the administrative appeal process. The good cause exceptions include situations where beneficiary access to items or services would be jeopardized, as defined in the rule: the provider is the sole community physician or sole source of essential specialized services in a community, or serves a large number of beneficiaries in a federally designated medically underserved area.
That last point connects enforcement to people served. When a withhold, sanction or enrollment action will disrupt services, plan for continuity of care before or alongside the action, where investigative needs allow. Coordinate with counties, Tribal Nations and case managers, and help people find another provider. Formal decisions about suspensions, hearings and exceptions belong to the responsible DHS offices and legal counsel.
