CMS Revocation of Billing Privileges
Experienced Legal Representation for Providers Facing Loss of Medicare Billing Privileges
CMS Appeals Team Lead
Former DOJ Attorney
CMS Appeals Team Lead
The Centers for Medicare and Medicaid Services (CMS) have broad authority to revoke healthcare providers’ billing privileges under federal healthcare programs. CMS can revoke a provider’s billing privileges on various grounds; and, once a provider’s privileges have been revoked, the provider can face a re-enrollment bar ranging from 1 to 10 years.
Revocation of a healthcare provider’s Medicare billing privileges can have other consequences as well. Providers can also face liability for recoupments, treble damages, and civil monetary penalties (CMP). If a CMS auditor or Medicare contractor uncovers evidence of intentional billing fraud, criminal charges could also be on the table.
Experienced Healthcare Defense Lawyers for CMS Revocation of Billing Privileges
Our lawyers defend healthcare providers, suppliers, and other entities that are facing revocation of their Medicare billing privileges. We are a team of highly experienced healthcare defense lawyers, many of whom prosecuted healthcare fraud cases at the United States Department of Justice (DOJ) before entering private practice. If your practice or business has received a revocation notification due to allegations of abusive billing practices, improper prescribing practices, or any other violation, we can help—but it is important that you contact us promptly.
Grounds for Revocation of Billing Privileges (Medicare Revocation)
Providers and other entities that bill Medicare, Medicaid, and other federal health care programs are required to strictly comply with these programs’ billing rules and regulations. Those that fail to comply can face serious consequences, including revocation of their billing privileges.
Regarding Medicare in particular, numerous issues uncovered during providers’ billing audits can lead to revocation. We defend healthcare providers and other entities that are facing revocation of their Medicare billing privileges and termination of their corresponding provider agreement due to allegations including (but not limited to):
- Failure to satisfy the Medicare enrollment requirements
- Double-billing Medicare and a private health insurance program
- Paying improper rebates or referral fees to an associated Medicare provider
- Relying on false or misleading information to bill for services provided to Medicare beneficiaries
- Failure to furnish supporting documentation verifying Medicare billings
- A pattern or practice of prescribing medications without valid prescribing authority
- A pattern or practice of prescribing Medicare services in an abusive manner
- Submitting false information in a Medicare revalidation application
- Providing services outside of the supervision of a supervising physician
- Providing services through a currently revoked provider
- Failure to comply with supplier screening requirements
- Misuse of billing numbers and other “immediate risks” to Medicare Trust Funds
Felony convictions for insurance fraud, financial crimes, and other adverse legal actions can pose risks for revocation as well. This includes legal actions both related and unrelated to an eligible professional’s conduct within his or her healthcare practice. If CMS determines that an offense reflects negatively on an eligible professional’s ability to comply with the Medicare billing rules and regulations on behalf of an enrolled provider, this can lead to revocation regardless of whether the offense was committed within the scope of the professional’s practice.
When considering whether to impose revocation (and, if so, the duration of revocation to impose), CMS also considers various other factors related to the provider’s circumstances and the specific violation(s) at issue. These include factors such as:
- The reason(s) for the violation(s) at issue
- The provider’s history of violations and final adverse actions or Medicare payment suspensions
- The length of time that the provider was in violation
- The amount that was improperly billed to Medicare
- The degree of risk that the provider poses to Medicare Trust Funds
- “Any other evidence that CMS deems relevant to its determination”
With that said, while CMS has discretion to impose revocation in many circumstances (and targeted providers can, and should, rely on this discretion when warranted), there are also certain circumstances in which providers may be subject to mandatory exclusion. If you are facing mandatory exclusion and permanent provider agreement termination, our healthcare defense lawyers can assist you in this scenario as well.
How Our CMS Defense Lawyers Can Help
We provide comprehensive legal representation for healthcare providers and other entities in all matters involving the U.S. Department of Health and Human Services (HHS), including CMS revocation and exclusion matters. Here are just some of the ways our CMS defense lawyers can help:
1. Protecting Providers’ Medicare Enrollment
If your practice or business has received a Medicare contractor’s request for access to its billing records and related Medicare enrollment files, or if your practice or business is facing revocation as the result of a Medicare audit, we can fight to protect your Medicare enrollment. We have extensive experience representing a wide range of clients during the audit process, including institutional providers, physician practices, hospitals, clinics, independent diagnostic testing facilities, and other entities.
2. Seeking Reversal of Medicare Revocation
If your practice or business has received a revocation notification, we may be able to seek a reversal before the revocation takes effect. This requires prompt action; and, as a result, if your practice or business is facing revocation, we strongly encourage you to contact us for a free and confidential consultation right away.
3. Filing Requests for Reconsideration
If securing reversal of your practice’s or business’s Medicare revocation is not an option, our lawyers can file a request for reconsideration with the appropriate Medicare Administrative Contractor (MAC). If you have grounds to fight revocation, our lawyers can use your practice’s or business’s billing records and other reliable evidence to seek to prove that revocation is unwarranted.
The MAC reconsideration process is just the first step in the administrative appeals process in cases involving revocation due to alleged noncompliance with Medicare requirements. There are several additional steps in the process, and our lawyers can navigate the process on your business’s or practice’s behalf as necessary.
5. Fighting to Protect Providers’ Ability to Bill the Medicare Program in Court
Finally, if the administrative appeals process does not produce a just result, we can fight to protect your practice’s or business’s ability to bill the Medicare program in court. Our healthcare defense lawyers have extensive litigation experience, and we can use our experience to fight for your practice’s or business’s ability to bill Medicare by all means available.
FAQs: Defending Against Revocation of Medicare Billing Privileges
My medical practice is at risk of losing its Medicare billing privileges. What should I do?
If your medical practice is at risk of losing its Medicare billing privileges, you should engage experienced defense counsel promptly. In this scenario, it is critical to ensure that you have an accurate and comprehensive understanding of why your practice is facing revocation, and you will need to thoroughly assess the validity of the allegations against your practice as well. Our team can assist with taking both of these key steps and then advise you accordingly.
Are healthcare providers required to provide CMS access to their billing records?
Generally, yes. Healthcare providers that bill Medicare are subject to being audited by CMS and its Medicare contractors. During audits, healthcare providers must provide access to their billing records—and, if they don’t, CMS and its auditors will err on the side of assuming billing noncompliance.
What is 42 CFR 424.535?
42 CFR 424.535 is the federal regulation that governs revocation of healthcare providers’ and other entities’ enrollment in the Medicare program. Under 42 CFR 424.535, providers and other entities can face revocation on numerous grounds, and defending against revocation requires an informed, strategic, and proactive approach based on a clear and comprehensive understanding of all pertinent federal laws, rules, and regulations.
When is a pattern or practice of prescribing Medicare services considered “abusive”?
A pattern or practice of prescribing Medicare services is considered “abusive” if it regularly results in the submission of improper claims for Medicare reimbursement. This can involve abusive billing practices such as upcoding and unbundling, as well as other prohibited practices such as misusing Medicare beneficiaries’ personal information and billing for services that do not qualify as “medically necessary” under the Medicare billing guidelines.
What is the effective date for a CMS revocation of billing privileges under Medicare?
Revocation effective dates are specified in 42 CFR 424.535, and are determined based, in part, on the reason for the revocation. For example, in cases involving alleged abuse of billing privileges, the revocation effective date is either: (i) “the earliest date of service on the claim or claims that is or are triggering the revocation;” or, (ii) “the last date of service on the claims in question.”
Schedule a Call with a Senior CMS Defense Lawyer at Oberheiden P.C.
If you need more information about defending against revocation of Medicare billing privileges, we invite you to schedule a complimentary initial consultation at Oberheiden P.C. Once you get in touch, we will arrange for you to speak with one of our senior CMS defense lawyers in strict confidence as soon as possible. To schedule an appointment, call us at 888-680-1745 or contact us confidentially online today.
