Federal regulations provide 22 distinct reasons that the Centers for Medicare & Medicaid Services (CMS) may use to revoke a healthcare provider’s or supplier’s Medicare billing privileges. Any revocation can have devastating impacts on a provider, but the grounds for revocation are often misunderstood. These are some of the most common reasons CMS will assert in revoking Medicare billing privileges.
Noncompliance: CMS may revoke a provider for noncompliance with Medicare enrollment requirements. This is somewhat of a catch-all and is often used when CMS or a contractor alleges technical issues with the myriad of requirements for a provider to maintain Medicare enrollment, such as issues with a provider’s surety bond, insurance policy, or business telephone lines. This reason for revocation is unique in two ways: the contractor often has authority to revoke without asking CMS to make the decision and the provider may have the opportunity to submit a Corrective Action Plan (CAP) demonstrating that they have addressed the issue.
Felony Convictions: CMS may revoke a provider when the provider or any of its owners or managers have been convicted in the last 10 years of any felony that CMS deems detrimental to the Medicare program or beneficiaries. This most often includes financial crimes such as insurance fraud or healthcare fraud but can include many others. A guilty plea or pretrial diversion program may still constitute a conviction. Moreover, even where a provider has previously disclosed the felony conviction, CMS may still use it as a reason to revoke. Where a provider is revoked for a felony, CMS will often make the revocation retroactive and back-date it to the date of the conviction.
Failure to Report: CMS may revoke a provider for failing to report certain information, whether in the provider’s Medicare enrollment application or upon the occurrence of certain events after the provider is enrolled. This reason may accompany other revocation reasons, such as where a provider does not report a felony conviction. If a provider makes the required disclosure, but does so late, CMS may consider the timeliness and materiality of the late disclosure.
Abuse of Billing Privileges: An abuse of billing privileges is defined in two ways. First, as billing for services that could not have been performed. For example, the physician was out of the country or the beneficiary was deceased at the time of the service billed. Second, where the provider has engaged in a “pattern or practice of submitting claims that fail to meet Medicare requirements.” CMS has asserted that as few as three non-compliant claims may be enough of a pattern to support a revocation. This type of revocation often comes after a contractor has alleged that a provider performed poorly on an audit, such as a Targeted Probe and Educate (TPE) review.
Failure to Provide Access to Documentation: This type of revocation can occur when CMS or one of its contractors requests medical records from a provider and the provider fails to respond. These requests generally will be mailed to the provider’s address on file in PECOS. It is therefore important for a provider to maintain a current address in PECOS and to respond to requests for records.
For over 35 years, Wachler & Associates has represented healthcare providers and suppliers nationwide in a variety of health law matters, and our attorneys can assist providers and suppliers in appealing a revocation of Medicare billing privileges. If you or your healthcare entity has any questions pertaining to healthcare compliance, please contact an experienced healthcare attorney at 248-544-0888 or wapc@wachler.com