Responding to a Medicare Revocation Action Effective Prior to November 4, 2019

I. What is a Medicare Revocation Action?

When a health care provider’s Medicare number is revoked, its billing privileges are terminated. Notably, the associated provider agreement is also automatically terminated. There are a wide variety of bases upon which a revocation action can be initiated. The two primary reasons for revocation we have addressed in recent months have included licensure-based actions and those resulting from a provider’s failure to report an adverse action or change in location.

• Noncompliance.Unfortunately, if a physician, falls out of compliance with applicable enrollment requirements, his or her Medicare billing privileges may be revoked. Typically, revocation actions associated with this reason result from a determination by a Medicare contractor that a physician or his / her practice no longer meets all of the necessary registration requirements. When this occurs, the contractor notifies the CMS Provider Enrollment & Oversight Group with the pertinent provider information and its recommendation that a revocation action be authorized.

  For instance, Medicare requires that physician services be furnished by a doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the state in which he or she practices. The Medicare Program Integrity Manual (MPIM) further elaborates on this basis for revocation in cases where a physician is not appropriately licensed: “…situations in which § 424.535(a)(1) may be used a revocation reason include [where]…[t]he provider or supplier is not appropriately licensed.” MPIM Ch. 15 § 15.27.2(A)(1)(c).

  This basis for revocation is especially pertinent in a large state like Texas, where the Texas Medical Board remains active with respect to disciplinary actions. At its June 10, 2016 meeting, the Texas Medical Board disciplined 78 licensed physicians and issued one cease and desist order. A significant number of these disciplinary actions resulted in licensure revocation or suspension. Each of these adverse disciplinary actions would likely result in the revocation of a physician’s billing privileges.

• Failure to Report.Should a provider fail to comply with its reporting requirements under 42 C.F.R. 424.516(d)(1)(ii) and (iii), which include “any adverse legal action” and / or “a change in location,” CMS may revoke the provider’s billing privileges. Additional reasons for revocation we have seen also include:
• Provider or Supplier Conduct.Under this regulatory provision, if a provider (or supplier), or an owner, managing employee, authorized or designated official, medical director, supervising physician or other health care personnel of the provider (or supplier) is excluded from the Medicare, Medicare or other federal health care program, the provider’s Medicare number can be revoked and its billing privileges terminated. This basis for revocation is especially harsh – it can be imposed based on the fact that a provider has failed to adequately screen out employees, staff and contractors that have been excluded from participation in one or more federal health benefit programs. Debarment or suspension from federal procurement and nonprocurement programs can also result in revocation.
• Felonies.If a provider (or supplier) or any owner or managing partner of the provider (or supplier) has been convicted of a federal or state felony within the past 10 years and CMS determines that the offense is detrimental to the best interest of the Medicare program, the agency may revoke the provider’s Medicare number.
• False or Misleading Information.

If a provider or supplier has certified as “true” false or misleading information on an enrollment application, its Medicare number may be revoked. Importantly, such an action may also constitute a violation of criminal law due to the submission of a “false statement” to the government.

• On-Site Review.If a program integrity contractor (such as a Unified Program Integrity Contractor (UPIC)) visits your office and makes a determination that your practice or agency is no longer operational or fails to meet another Medicare enrollment requirement, the UPIC will recommend to CMS that your Medicare billing privileges be revoked. This often occurs when a provider moves offices and either fails to notify Medicare of the move in a timely fashion OR a Medicare contractor claims that it never received notice of the change in location. Importantly, it isn’t merely enough for a provider to be able to show that notice of the change in location was actually sent – you need to be able to prove that the Medicare contractor RECEIVED the notice.
• Misuse of Billing Number.If a provider knowingly sells its billing number or allows another individual or entity to use its billing number, CMS can revoke the provider’s billing privileges. Exceptions are permitted for a valid reassignment of benefits or a change of ownership.
• Abuse of Billing Privileges.Should CMS determine that a provider has engaged in abusive billing practices, it can revoke the provider’s billing privileges. Examples cited in the regulation include:
  

  Billing for services provided to a Medicare beneficiary that is deceased.

  Billing for services when either the physician or the beneficiary is not in the state or the country when the service was supposedly rendered.

  Billing for services that require certain testing equipment when that equipment was not available at the location where the services were allegedly rendered.

  CMS may also revoke a provider’s billing privileges if it determines there is a pattern or practice of submitting claims that fail to meet Medicare’s requirements. When considering this basis for revocation, CMS considers:

  The percentage of claims that were denied.

  The reasons for claims denials.

  Whether or not the provider has a history of previous final adverse actions.

  The length of time over which a pattern or practice or improper billing has taken place.

  How long the provider has been enrolled in the Medicare program.

  Any other information that CMS feels is relevant in its determination of whether a pattern or practice of improper billing has occurred.