Burr & Forman

05.15.2017   |   Articles / Publications

Revocation of Enrollment in the Medicare Program- A Powerful Weapon in Medicare’s Arsenal

Reprinted with Permission from the Birmingham Medical News

In 2014, CMS issued a final rule related to 42 CFR 424.535, which gave CMS expanded authority to impose penalties on providers. Although the rule is several years old, the first version published in 2006, the rule has been expanded over the years, and CMS’s use and enforcement appears to be increasing. Therefore, it is important to understand the basis of revocation and the implications for providers who receive notification from CMS or its MAC contractor regarding revocation.

The regulation allows CMS to revoke a provider’s billing privileges under the following circumstances:

  1. Noncompliance with enrollment requirements;
  2. Provider or supplier conduct – being barred or excluded from Medicare;
  3. Felony convictions in the past 10 years which would be detrimental to Medicare or its
    beneficiaries;
  4.  False or misleading information – the provider certified as true false or misleading
    information when enrolling in the Medicare program or to maintain enrollment in the
    program;
  5. On-site review – if during onsite review, CMS determines the provider is no longer operational
    or does not meet provider enrollment requirements;
  6. Grounds related to provider screening requirements – failure to submit an application fee or
    CMS is unable to deposit funds submitted for the application fee;
  7. Misuse of billing number – knowingly sells or allows another to use its billing number (does
    not include assignment of billing number);
  8. Abuse of billing privileges – submitting claim for services that could not have been furnished
    (i.e., beneficiary is deceased) or pattern and practice of submitting claims that do not meet
    Medicare requirements;
  9. Failure to report changes in location, ownership or adverse legal action;
  10. Failure to document or provide CMS access to documentation;
  11. For a home health provider, failure to meet initial reserves operating fund requirement;
  12. Medicaid termination;
  13. Prescribing authority – suspension or revocation of DEA number or state revocation or
    prescribing authority;
  14. Improper prescribing authority – a provider has a pattern or practice of prescribing Part D
    drugs that fails to meet Medicare requirements or is abusive or is a threat to the health and
    safety of Medicare beneficiaries.

Download the full article, “Revocation of Enrollment in the Medicare Program- A Powerful Weapon in Medicare’s Arsenal,” written by Angie C. Smith.

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