Medicare Termination and Revocation Defense

The Centers for Medicare and Medicaid Services (CMS) can revoke or terminate a health care providers enrollment in Medicare, thereby ending their billing privileges. This termination or revocation may take place if CMS determines that the health care provider has committed any one of a number of infractions. The loss of Medicare billing privileges can have a devastating effect on a health care practice, so it critically important to avoid a violation. Here, we discuss reasons why a health care provider might have billing privileges revokes, and options for Medicare revocation defense.

The Code of Federal Regulations (CFR), Section (§) 424.535, lists the following reasons for revocation of billing privileges:

  • Noncompliance – A provider must meet all Medicare enrollment requirements concerning licensing. If a provider is involved in a disciplinary action, his license may be suspended or revoked. This will result in noncompliance of enrollment requirements.
  • Provider Conduct – This refers to any provider or supplier who has either been excluded from participation in Medicare or another Federal health care program. It also includes a provider who has been debarred or suspended in other Federal procurement or nonprocurement program or activity.
  • Felonies that the providers, owners or their managers have been convicted of in the past ten (10) years.
  • False or Misleading Information that the provider certified as “true”.
  • On-Site Reviews by CMS that determines the provider is no longer operational or has failed to satisfy any Medicare enrollment requirements.
  • Grounds related to provider and supplier screening requirements refers to providers who don’t submit an application fee or hardship exemption set forth in CFR’s Section (§) 424.514.
  • Misuse of Billing Number includes providers who have knowingly sold or permitted another entity to use its billing number.
  • Abuse of Billing Privileges refers to a provider submitting a claim that couldn’t have been furnished to an individual. For example, if the individual is deceased, the provider isn’t located in the state when services were provided, or any equipment necessary for testing isn’t present where the testing was said to have occurred.
  • Failure to Report refers to a provider who doesn’t comply with CMS requirements to report adverse legal actions or a change in location of the provider’s practice.
  • Failure to Document or Provide CMS Access to Documentation.
  • Initial Reserve Operating Funds refers to a provider’s inability to provide supporting documentation that it meets the initial reserve operation funds requirement.
  • Medicaid Termination of a provider by a state Medicaid agency.
  • Prescribing Authority – This occurs when the provider’s ability to prescribe medication has been revoked or suspended.
  • Improper Prescribing Practices. The provider’s pattern of prescribing prescription medication threatens the health of a Medicare beneficiary.

Response to Revocation

If a provider’s billing privileges are revoked, the revocation will last for a period of one to three years, depending on the circumstances. After this, the provider must submit a new application to CMS to reenroll.

If your medical practice or health care related business receives the dreaded notice of revocation or termination, what are your options for Medicare revocation defense? One option is to file a corrective action plan (CAP). The other option is a request for reconsideration. It is critically important to act quickly, because there are time limits associated with Medicare revocation defense, but it is also important to consider all the ramifications before making a decision. If you receive a notice of Medicare revocation or termination, it’s best to consult an experienced health law attorney to help you determine the best course of action.