Medicare Payment Suspension & Termination

Medicare Payment Suspension & Termination2018-10-25T17:44:16+00:00

Medicare Payment Suspension

The Centers for Medicare & Medicaid Service (CMS) may suspend a provider or suppliers’ payments under the following circumstances:

  • Fraud or willful misrepresentation,
  • When an overpayment exists, however no final overpayment amount has been determined, or
  • When payments already made (or future payments) may be incorrect.

Suspensions will be initiated based upon either a request from a Medicare contractor, or from law enforcement.

If your business’s Medicare payments have been suspended, the suspension can remain in place for months, and must be reevaluated every 180 days to determine the appropriateness of the ongoing suspension.

To safeguard your business from payment interruption, providers and suppliers should ensure they have effective compliance measures in place. Specifically, special attention should be paid to the business’s billing practices, and current Medicare policies and procedures concerning coverage and claims determinations.

It is far better business practice to prevent a payment suspension prior to interruption of payments. However, a provide or supplier may be able to receive withheld payments after a suspension is lifted.

abuse billing privileges - Medicare Payment Suspension & TerminationBilling Privileges Revocation

Allowed for the Code of Federal Regulations (CFR), Section (§) 424.535, CMS can revoke billing privileges for a list of reasons including Abuse of Billing Privileges. For example, if an 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, the provider submitting a claim for testing that couldn’t have been furnished to the individual, could qualify.

Medicare Termination / Revocation

The Centers for Medicare and Medicaid Services (CMS) can revoke or terminate a healthcare providers enrollment in Medicare, thereby ending their billing privileges. This termination or revocation may take place if CMS determines that the healthcare provider has committed any one of a number of infractions. The loss of Medicare billing privileges can have a devastating effect on a healthcare practice, so it critically important to avoid a violation. Here, we discuss reasons why a healthcare provider might have billing privileges revoked, 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 healthcare program. It also includes a provider who has been debarred or suspended in other Federal procurement or non-procurement 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 healthcare 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 Medicare attorney to help determine the best course of action.