The Centers for Medicare and Medicaid Services (CMS) has the legal authority to revoke health care providers’ and suppliers’ billing privileges. This right exists as the federal agency’s initiative against overpayments and fraud.
Although its intentions are meant to protect the agency, revoking Medicare privileges brings consequences. Health care providers and suppliers may face licensing issues and total exclusion from state and federal healthcare programs.
You may face these consequences as a provider or supplier. Even if you have been compliant with Medicare regulations, the CMS may detect minor lapses and cite them as abuse.
The CMS’s revocation authority began in 2006. Its primary goal was to prevent Medicare fraud. In the beginning, the CMS limited Medicare revoking authority. Amendments expanded the agency’s authority to revoke billing privileges, which allowed the CMS to exercise a broader set of criteria for tagging providers for their conduct and alleged non-compliance.
The CMS released a final rule regarding its revocation authority in 2014 that expanded its scope of revoking Medicare billing privileges. The CMS continues to make additional proposals to expand its revocation authority further. Although these continued proposals help prevent dishonest providers, all Medicare participants suffer consequences, including:
The CMS enforces its authority and exercises consequences strictly. Comply with its regulations proactively to prevent revocations. You must be responsive when facing investigations and relevant audits.
Despite your efforts, your practice faces risk considering the harsh management and approaches of the CMS. However, you can still challenge all consequences associated with billing privilege revocations. Consider getting help from seasoned Medicare lawyers like our team at the Fenton Law Group.
The Code of Federal Regulations establishes the grounds for CMS’s revocation authority in 42 CFR §424.535. It allows CMS to revoke an enrolled provider’s Medicare billing privileges. The authority can cancel the provider’s corresponding or supplier agreement. CMS may pursue such revocations if you meet the established reasons, which include:
Noncompliance involves failure to meet any of the CMS’s enrollment regulations for your provider or supplier type. In addition, failure to submit any corrective actions in line with your identified deficiencies counts as noncompliance. Some deficiencies include inappropriate licenses, nonpayment of user fees, and lack of a business address.
This ground for revocation involves the provider’s or supplier’s suspension, debarment, or exclusion from any federal health care program or personnel, including Medicare and Medicaid.
Any providers or suppliers who have been convicted of a federal or state felony offense within the past decade can face revocation. Violations include felony crimes against persons (assault, rape, murder), financial crimes (extortion, embezzlement, income tax evasion), and malpractices that put the Medicare program at risk.
When providers or suppliers submit their Medicare enrollment application or revalidation application with misleading or false information, they may face fines, imprisonment, or both.
Upon on-site review, the CMS may find reliable evidence that you fail to satisfy CMS Medicare enrollment requirements.
You may face billing privilege revocations for institutional providers when you fail to submit an application fee or hardship exception request. Hardship exception requests must be in line with Medicare revalidation application requirements.
When providers or suppliers knowingly sell or allow other entities to use their Medicare billing numbers, they are guilty of misuse. Exceptions include those in a valid reassignment of benefits or ownership changes.
Billing privilege abuse may involve providers or suppliers who submit claims for services not given to specific individuals on the date of service. For example, the beneficiary is deceased, or the directing physician is not in the state or country upon billing.
Providers who fail to report any adverse legal actions or changes in their practice locations within 30 days of the event face revocation. This applies only to physicians, non-physician practitioners, and physician or non-physician organizations.
Providers or suppliers who fail to comply with documentation or CMS access requirements meet the revocation criteria specified in § 424.516(f).
Providers or suppliers who face CMS revocation can appeal the agency’s decision. The appeals process involves multiple levels. Here is a general outline of the process for an idea of what to expect:
Providers and suppliers who face the CMS’s revocation authority may correct their identified deficiencies through the CAP process. However, per the 2014 final rule, the only providers who can undergo this process are those who face non-compliance by revoking their Medicare billing privileges.
Eligible providers and suppliers must craft and submit their CAP within 30 days of their revocation notice. Their CAP must contain verifiable evidence proving that they comply with the appropriate Medicare requirements.
Approved CAPs will result in revocation withdrawal, allowing providers to regain their billing privileges within a specific date. Meanwhile, providers still have appeals rights when the CMS denies their CAP.
This stage is the first level of appeal for providers to challenge revocation for reasons aside from noncompliance. You must submit your reconsideration appeal to your Medicare Administrative Contractor (MAC) within 60 days of receiving your revocation notice. Reconsideration hearing officers from your MAC will review and decide your appeal case. The CMS will determine on your appeal if your revocation is due to abuse of Medicare billing privileges.
Appellants must include relevant information and evidence in their appeal for the hearing officer to consider before proceeding to the next stages. The Administrative Law Judge (ALJ) may consider submitting new evidence even in later stages if there is a good cause.
You could proceed to a hearing with the ALJ if you receive an unfavorable decision with your reconsideration. Providers must submit written appeal requests to the ALJ within 60 days of receiving your reconsideration decision. This process requires an attorney to represent the CMS, so it’s wise to consider your own representation.
Should the ALJ’s decision leave you unsatisfied, you can request the Departmental Appeals Board’s (DAB) Appellate Division to review their decision. When seeking a DAB review, you must write to the board within 60 days of receiving the ALJ’s decision. Should the DAB’s decision be unfavorable, you can proceed to judicial review by filing a civil action in a U.S. district court within 60 days of the board’s decision.
The CMS revokes the Medicare billing privileges of providers and suppliers as a preventive measure against dishonest contributors. However, their revocation authority is so wide that even the smallest mistakes could cause devastating consequences for providers and suppliers.
Affected providers can appeal the CMS’s revocation actions against them, but the appeal process is complicated and involves tedious hearings and document collection. Consider getting a legal professional to manage your appeal to restore your Medicare billing privileges.
Fenton Law Group has attorneys who specialize in Medicare revocations and appeals. We have a deep understanding of the Medicare program and experience in resolving enrollment issues and restoring billing privileges. Learn more about the range of our successful Medicare audits, appeals, and overpayment disputes.