Revocation of Medicare billing privileges can be devastating for providers and suppliers. Revocations not only affect the provider or supplier’s ability to bill Medicare in the future, but it can trigger many other actions that will have a damaging effect on a provider’s practice. Issues that can result from revocation include overpayment recovery, termination from Medicaid, loss of employment, re-enrollment bar, licensing action, and credentialing issues. Therefore, providers and suppliers must be aware of their appeal rights and the lasting effect a revocation will have in their career or practice.
Our attorneys are dedicated to helping providers and suppliers maintain their ability to practice and bill payers. We defend providers and suppliers who have been denied enrollment or had their Medicare billing privileges revoked. We also assist providers and suppliers with other issues that can result from the revocation and the basis of the revocation. Our team of attorneys includes a former Medicare attorney who has extensive experience in Medicare enrollment and reimbursement issues, including revocations.
Medicare may revoke a provider or supplier’s enrollment, and any other agreement, for reasons contained in 42 CFR § 424.535(a). The most common reasons are:
A provider or supplier who is revoked from the program, will receive a letter from their contractor. The letter will state the grounds for revocation, the effective date of the revocation, the re-enrollment bar, and the revocation’s impact on the provider or supplier’s other locations.
Medicare revocations may cause the following issues:
1. Effective Date
Generally, the effective date of a revocation is 30 days after the revocation notice is mailed. However, in certain circumstances, CMS can issue an earlier effective date. For example, revocations base on adverse actions will have a revocation effective date of the date of the final adverse action. In cases where the effective date is prior to notice of the revocation, the provider or supplier may face recovery action for payments made for services or items provided after the revocation effective date. Our attorneys may be able to challenge the effective date, and thus prevent overpayment recovery and allow payment of claims up to the new effective date.
Overpayment recovery can have a devastating effect on providers and suppliers. Not only does a revoked provider or supplier lose their ability to bill Medicare, the largest payer, but they may also be required to forfeit payments received for services rendered after the effective date of the revocation. Depending on the extent of the revocation and overpayment, the amount could easily be hundreds of thousands of dollars. Our attorneys may be able to challenge the overpayment amount and help reduce the amount in the event that restoration of billing privileges is unsuccessful.
3. Re-enrollment Bar
In most cases, a revoked provider or supplier is barred from re-enrollment for a minimum of one (1) year and a maximum of three (3) years. Depending on the basis for revocation, the re-enrollment bar may apply to all of the provider’s practice locations or only the location at issue. Contractors determine the re-enrollment bar based on the severity of the basis for revocation. Providers and suppliers may appeal the re-enrollment bar.
1. Reversing Revocation Based on Owner or Employee’s Wrongdoing
Revocations for adverse activity of an owner, managing employee, an authorized or delegated official, or other health care personnel of the provider or supplier’s may be reversed if the provider terminates its relationship with the wrongdoer. Providers must submit proof of termination within 30 days to their contractor. Contractors have the authority to rescind the revocation.
2. Corrective Action Plans (CAP)
If the denial or revocation is based in whole or part on deficiencies (§ 424.535(a)(1)) which can be corrected, providers and suppliers may submit a corrective action plan showing they are in compliance with Medicare requirements. CAPs must be submitted within 30 days of the denial or revocation and must comply with certain requirements. (see CAPs for information on how to prepare CAPs). The contractor must deny or approve the CAP within 60 days of receipt. Approval of the CAP rescinds the denial or revocation. Contractors may adjust the billing effective date. Submitting a CAP does not preserve appellate rights or toll the appeal deadline. Therefore, it is critical that CAPs comply with the requirements and contain sufficient evidence of compliance. Contact our attorneys to determine if a CAP is the best option for you. If so, our attorneys will help prepare a CAP and ensure your appeal rights are preserved.
Providers and suppliers can also submit a reconsideration request to their contractor. Reconsideration requests must be submitted within 60 days of receipt of the notice of denial or revocation. Failure to timely submit a reconsideration request is a waiver of all further appeal rights. A hearing officer not involved in the initial determination will make a determination upholding or overturning the revocation or denial within 90 days of the receipt of the request. Evidence may be submitted for consideration prior to the reconsideration determination. Future appellate proceedings may reject any evidence that was not submitted for reconsideration. Therefore, you should obtain assistance from an experienced attorney to prepare your reconsideration request.
4. Administrative Hearing (ALJ)
If providers and suppliers are unsuccessful with the reconsideration, they may appeal the decision to an administrative law judge (ALJ) with HHS. A request for an administrative hearing must be properly filed with 60 days of receipt of the reconsideration decision. At this point, the case will be prepared by an experienced CMS attorney and will be subject to administrative procedures. Therefore, it is strongly advised that providers and suppliers retain an attorney to handle the appeal. An attorney will be able to prepare the case (collect evidence, cross-examine witnesses, file briefs, etc.), attempt settlement, and represent your interests during the hearing. Many cases are settled prior to the hearing.
5. Departmental Appeals Board (DAB)
Both CMS and providers and suppliers can appeal an ALJ decision to the DAB. A request for a DAB review must be filed within 60 days after the ALJ renders its decision. As with ALJ hearings, DAB proceedings are formal and subject to specific procedures. The DAB has authority to deny review of the case. Therefore, providers and suppliers should retain an attorney that is experienced with DAB proceedings to prepare the request.
6. Judicial review
A provider or supplier may seek judicial review if they are unsatisfied with the DAB’s decision by filing a civil action in District court within 60 days.
If you have received a letter of revocation, contact our attorneys immediately. We will discuss your options and help prepare and timely file your appeal. Even if the revocation is the result of an obvious error by the contractor, we advise you seek help from an attorney. Revocations can result in significant loss of revenue, overpayment recovery, and other collateral consequences for many years to follow. Our attorneys will help you defend your billing privileges and prevent further recovery and collateral consequences.