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When Medicare Revokes Billing Privileges: Your Legal Defense Options

When Medicare Revokes Billing Privileges: Your Legal Defense Options

Losing your Medicare billing privileges can be devastating for healthcare providers. Not only does it affect your ability to bill Medicare now, but it also bars you from re-enrolling for 1-3 years depending on the reason for revocation. However, providers facing revocation have legal options to appeal and defend their billing privileges. This article will cover key things providers need to know, including grounds for revocation, the appeals process, and proactive steps to take.

Understanding Medicare’s Revocation Authority

Medicare gained the ability to revoke billing privileges back in 2006, though initially only in limited cases. Over time, regulations expanded Medicare’s revocation powers substantially through rulemaking and legislation. This gave Medicare a broad net to catch non-compliant and fraudulent providers.In 2014, the Centers for Medicare and Medicaid Services (CMS) released new rules significantly expanding their authority to revoke billing privileges. They continue proposing expansions to this day. So more providers are facing potential revocation than ever before.

Main Reasons Medicare Can Revoke Billing Privileges

Medicare can revoke billing privileges for a variety of reasons under 42 CFR §424.535. Some major grounds for revocation include:

• Exclusion from Medicare or Medicaid: The provider or any staff are excluded from federal healthcare programs. This includes being on the List of Excluded Individuals and Entities (LEIE).
• Terminated from Medicaid/CHIP: The provider’s Medicaid or CHIP billing privileges were terminated by a state.
• Abusive Billing: This includes billing for services not rendered. It also covers patterns of non-compliant billing, like excessive denials or improper coding.
• Felony Convictions: The provider or manager is convicted of a felony that CMS deems detrimental to Medicare beneficiaries or program integrity.
• Misuse of Billing Number: Such as letting someone else use your billing number or using someone else’s.
• False Information: Providing false info on enrollment applications or cost reports.
• On-Site Review Problems: Failing to cooperate with inspections or provide medical records.
• Prescribing Authority Revocation: For physicians, losing legal authority to prescribe medications.

Medicare can also revoke privileges for a pattern of submitting claims that fail to meet Medicare requirements, even if not fraudulent. This is under CMS’ expanded authority to address “abuse of billing privileges.”

The Medicare Revocation Appeals Process

Providers facing revocation of their Medicare billing privileges have the right to appeal. There are several levels to the administrative appeals process:

1. Corrective Action Plan

For some revocation reasons, Medicare may allow submitting a Corrective Action Plan (CAP) showing steps taken to fix the deficiencies. If approved, the revocation is withdrawn. If denied, you can still proceed with further appeals.

2. Reconsideration

This is the first level of appeal for most revocations. A request for reconsideration must be filed within 60 days of the revocation notice. Additional documentation can be submitted to support overturning the revocation.Most reconsideration appeals go to the Medicare Administrative Contractor (MAC). But for billing abuse revocations, CMS handles the appeal directly.

3. Administrative Law Judge (ALJ) Hearing

If reconsideration fails, the next step is requesting review by an Administrative Law Judge. This must be filed within 60 days of the reconsideration decision. ALJs take a fresh look at the facts to make a new determination.

4. Medicare Appeals Council

The final administrative appeal level is the Medicare Appeals Council. They review the ALJ’s decision for errors of fact or law. Like with lower levels, they can reverse the revocation after reviewing the evidence.Once these administrative appeals are exhausted, the only remaining option is seeking judicial review by filing suit in federal district court within 60 days of the final decision.

Proactive Steps Providers Can Take

The best defense is a strong offense. Taking proactive steps can help avoid revocation and put providers in a better position if it occurs:

• Conduct regular self-audits to catch and fix any compliance issues early.
• Implement a compliance program, including training staff on proper billing.
• Perform internal reviews when employees are terminated to address any problematic billing.
• Carefully screen new hires like doing background checks to avoid those with integrity issues.
• Respond promptly to any Medicare requests for records or documentation. Failing to cooperate can itself trigger revocation.
• Seek legal counsel early if facing audits, investigation, or potential revocation. Don’t delay until it’s too late.
• Consider settlement if revocation seems likely. Medicare may agree to a settlement allowing continued enrollment if problems are corrected.
• Have appeal arguments ready in case revocation occurs. This includes compiling documentation and evidence to support your appeal.
• Be proactive with patients if billing privileges are revoked. Make arrangements to continue care and transition them to new providers.

Conclusion

Losing Medicare billing privileges can put medical practices in jeopardy. But providers facing revocation are not powerless. Understanding the grounds Medicare can use to revoke privileges, navigating the appeals process, and taking proactive compliance steps are critical to defending your practice. With the proper preparation and legal guidance, providers can avoid, fight, and overcome threats to their Medicare enrollment and billing privileges.