The National Practitioner Data Bank (NPDB) is a database meant to facilitate easy access to reports of medical malpractice and adverse actions taken in response. All healthcare professionals should be aware of the impact that an NPDB report can have on their careers.
While the reports are not made available to the general public, they can be accessed by hospitals, licensing boards, professional societies, and other healthcare institutions, who may then refuse to work with you due to a report. The database’s scope is national, so you cannot avoid the effects of previous actions by practicing in another state.
In this article, you will learn about Medicare revocation, an action reportable to the NPDB, and how to navigate the appeals process.
There are 14 main reasons for Medicare revocation by the CMS, detailed in 42 CFR §424.535(a) of the Code of Federal Regulations. These reasons are:
Medicare revocation is detrimental to healthcare practitioners. Even if you have not been intentionally dishonest in your practice, you may still face a revocation due to an oversight. Any provider whose Medicare enrollment has been revoked has the option of submitting an appeal to CMS. There are several levels to the process.
Under the Final Rule that took effect in February 2015, only providers who faced revocation for noncompliance could submit a CAP in order to appeal the decision. Providers are required to submit their CAP within a 30 day-period after the revocation notice. The CAP is required to contain demonstrable evidence that verifies the provider has corrected their noncompliance. If approved, the provider’s previous Medicare billing privileges will be returned, effective on the date that the provider became fully compliant with enrollment requirements. If denied, the provider has the option of submitting another appeal.
The first stage of the process for most providers is the reconsideration stage. Providers are required to submit an appeal within 60 days of the revocation notice. The appeal must contain all additional evidence or information that the provider wants their hearing officers to take into account. No additional information may be submitted at later stages unless the Administrative Law Judge (ALJ) deems it necessary.
Most appeals should be submitted to the provider’s Medicare Administrative Contractor (MAC) unless the reason for revocation falls under an abuse of billing privileges, in which case the CMS will handle the appeal.
If the reconsideration stage failed to yield the provider’s desired result, an ALJ hearing before the Departmental Appeals Board’s (DAB) Civil Remedies Division may be requested. The request for an ALJ hearing must be submitted within 60 days after the MAC or CMS made their reconsideration decision. During the hearing, the provider and a CMS attorney present written arguments, evidence, and testimony. Based on the material presented by both parties, the ALJ will issue their decision regarding whether or not the CMS’ revocation authority was applicable in the situation.
In the event that either the provider or CMS is unsatisfied with the ALJ’s decision, they have the right to request a review from the DAB’s Appellate Division. This request must be submitted within 60 days of the ALJ’s decision. Within the appeal process, DAB has the final administrative decision.
If the provider is still unsatisfied with the DAB’s decision, they may choose to go to a United States District Court and file a civil case. This must be filed within 60 days of the DAB’s decision.
In most scenarios, the revocation will take effect 30 days after the revocation notice has been sent. During this time, it is in your best interest to begin the appeals process and speak to a lawyer who can help you build your case.
You typically need to wait one to three years after the date of revocation. The specific period will depend on the re-enrollment bar instituted by CMS. You are not allowed to re-enroll during this period.
While you are not allowed to submit claims for services furnished after revocation, you may still submit claims for prior services. However, you must submit these within 60 days of the revocation.
If your appeal was approved, and your privileges are retroactively reinstated, you can submit claims for services furnished during the revocation period.
It can be difficult to ensure that you and your group are always in compliance with Medicare enrollment requirements. If you are ever in need of assistance in appealing a revocation or simply have questions about compliance, feel free to contact us at Fenton Law Group.