Medicare Reporting Obligations

Providers, organizations, and suppliers enrolled in Medicare have a continuing duty to report changes in their enrollment information to Medicare. Changes must be reported accurately and timely to the provider or supplier’s Medicare contractor or NSC. Failure to timely report changes can result in revocation of billing privileges and bar re-enrollment for up to three years. Changes to Medicare enrollment data can affect eligibility and result in revocation of billing privileges. Our attorneys assist with reporting changes and revocation and overpayment proceedings related to enrollment eligibility.

Reportable Events and Timeliness Standards

Physicians, non-physician practitioners, physician and non-physician practitioner organizations, and Independent Diagnostic Testing Facilities (IDTFs) must report:

  • A Change in ownership within 30 days of the change;
  • Any adverse legal action within 30 days of the event;
  • A change in practice location within 30 days of the change; or
  • All other change to previously reported enrollment data within 90 days of the change.

DMEPOS must report any change to previously reported enrollment data within 30 days of the change.

Other suppliers and providers must report:

  • A change in ownership, control, authorized officials, or delegated officials within 30 days of the change;
  • A revocation or suspension of a federal or state license or certification within 30 days of the event; or
  • All other change to previously reported enrollment data within 90 days of the change.

Change of information applications must be received by MAC within the required reporting period. “Days” refers to calendar days, not business days.

Reportable Final Adverse Legal Actions

Anyone who reports a change of information or ownership is asked to report final adverse legal actions. Final adverse legal actions that are required to be reported by providers, suppliers, and owners within 30 days include:

  • Suspension or revocation of a license to provide health care;
  • Revocation or suspension by an accreditation organization;
  • Federal or State felony conviction that is detrimental to Medicare or its beneficiaries;
  • Misdemeanor in connection with the delivery of health care related to:
    • the delivery of an item or services under Medicare or a state health care program;
    • patient abuse or neglect; or
    • theft, fraud, embezzlement, breach of fiduciary duty, or other financial misconduct.
  • Misdemeanor or felony convictions related to:
    • unlawful manufacturing, distribution, prescribing or dispensing of a controlled substance; or
    • Interference or obstruction with an investigation into any criminal offense that is grounds for exclusion.
  • Exclusion or debarment from participation in a Federal or State health care program; and
  • Medicare imposed revocation of any Medicare billing privileges or current suspension of Medicare billing privileges.

“Suspension and revocation” includes surrender of a license to practice health care during formal disciplinary proceedings.

“Conviction” includes a plea of guilty or nolo contendere, or a judgment of conviction against an individual or entity, regardless of expungement or pending appeals or motions.

“Detrimental to Medicare and its beneficiaries” has been interrupted by some MACs to include all felony convictions, not just felonies enumerated in 42 CFR § 424.535(3)(ii). Therefore, contact our attorneys for assistance in determining whether the felony conviction is reportable as an adverse legal action. Our attorneys are highly experienced in representing providers with enrollment issues. If our attorneys determine that the felony conviction is reportable, our attorneys will help you prepare an explanation to your MAC and represent you during any hearings or appeals.

Adverse legal actions affect enrollment eligibility and are therefore likely to result in a further investigation by MAC. If MAC determines that provider, supplier, or organization no longer meet the enrollment requirements, they will seek revocation of billing privileges. Providers, suppliers, and owners have the right to appeal a revocation determination. For more information about revocations see Medicare Revocations.

Reportable Change of Ownership and Managing Control Events

Failure to report a change in ownership (CHOW) is one of the most common reporting failures. Entities that participate in Medicare must report the following events as change of ownership:

  • Corporations must report a merger of a corporation into another corporation or a consolidation of two or more corporations into a new corporation.
  • Partnership organizations must report a change in ownership the removal, addition, or substitution of a partner that affects ownership.
  • Sole proprietorships must report a transfer of title or property.
  • Entities that lease a provider facility must report the lease.

Independent diagnostic testing facilities must report a change in supervision, in addition to the above change in ownership events, within 30 days.
Owners are individuals or corporations with 5 percent or more ownership or controlling interest. Change of ownership is required to be reported by both the old and new owners. See CHOW for more requirements. Failure to timely report CHOWs can result in suspension of payments and other sanctions.

Other changes in business structure that do not meet the above requirements for a CHOW reporting should be reported as an information change. Information changes related to ownership and business structuring include a change in legal business name and/or TIN and stock transfers.

Other Reportable Events

Other reportable events include:

  • Change in practice status (e.g. retirement, voluntary withdrawal from Medicare, or voluntary surrender of a license to practice not during formal disciplinary proceedings);
  • Change in business structure (see above);
  • Changes to banking arrangements or payment information;
  • Change in billing agency; and
  • Change in correspondence or special payment address.

How to Report Changes

Providers and suppliers must report changes, additions, or deletions to their enrollment information on the applicable CMS-855 form. The form must be submitted to PECOS or the provider or supplier’s MAC. DMEPOS must report enrollment information changes to the National Supplier Clearinghouse (NSC).

Providers, suppliers, and owners often report basic information regarding felonies and licensure action. This often results in a revocation determination. While not required, submitting a narrative that explains the conviction or licensing actions in the best possible light may be helpful. Our attorneys work with providers, suppliers, and owners to prepare narratives that accurately report the event and address factors that CMS considers when determining whether the event is grounds for revocation. When preparing narratives on behalf of clients, our goal is to prevent an initial revocation determination. This will save the provider not only the cost and time involved in appealing an initial revocation, but it may also prevent overpayment action and loss of ability to bill Medicare during the appeal process.

Sanctions:

Revocation

Failure to report can result in revocation of billing privileges. Failure to timely report (reporting after the required timeframe) generally does not result in revocation, although CMS has the authority to revoke billing privileges. Failure to provide information upon request can also result in revocation of billing privileges. See Medicare Revocations for more information.

Overpayment Recovery

Revocations based on felony convictions described in 42 CFR §424.535(a)(3), license suspension and revocation, Federal exclusion or debarment, and provider or supplier no longer operational are effective from the date of the exclusion, debarment, felony conviction, license suspension or revocation, or the date that CMS or MAC determined that the provider or supplier is no longer operational. Therefore, if payments are made to providers for services performed after the effective date of the revocation, MAC can initiate action to recover the overpayment.

Re-enrollment Bar

Provider, suppliers, and owners who have their Medicare billing privileges revoked are barred from re-enrollment for a minimum of one year and a maximum of three years (with the exception of revocations for failure to timely respond to requests for information). MAC will determine the re-enrollment bar period on a case-by-case basis. However, revocations based on felony convictions bar re-enrollment for three years from the date of the revocation determination.

Appeals

Providers, organization, and suppliers who receive a revocation determination from their MAC have the right to request an appeal. See Medicare Revocations for more information.

How We Can Help

Reporting certain events can negatively impact your Medicare billing privileges. Therefore, contact our attorneys for assistance in reporting adverse events and licensure issues. Our attorney can help prevent revocations and subsequent overpayment action and re-enrollment bars.

Our team of licensing, criminal defense, and transactional attorneys are experienced in Medicare reporting. Our attorneys help providers, suppliers, and owners determine their reporting requirements and help timely and accurately report changes when required. We help prepare change applications, narratives, and additional information as requested by MAC. We also represent providers, suppliers, and owners during revocation appeals related to failure to report and noncompliance with enrollment requirements.

IMPORTANT: There may be additional state Medicaid and licensing Board reporting requirements and NPDB issues that are not addressed in this article. Contact our attorneys for information about other reporting obligations.


Let Us Help You Now
  • Disclaimer