There are 14 Reasons or grounds for Medicare to issue a revocation letter (Each reason is discussed in detail in separate posts..) at 42 CFR 424.535(a), and in the Program Integrity Manual, Ch 15, Sec 15.27.2
- Not in Compliance with Medicare Requirements stated in the enrollment application or in the regulations governing enrollment
- Excluded/Debarred from Federal Program – provider/supplier, or any owner, managing employee, authorized or delegated official, medical director, supervising physician or “other healthcare personnel”
- Felony conviction – ANY felony in last 10 years CMS finds to be detrimental to the Medicare program or its beneficiaries
- False or Misleading Information on Application – revocation PLUS fines or imprisonment or both
- On-Site Review/Other Reliable Evidence that Requirements Not Met – these are the failed site visits (which usually also list Reason 1 above)
- Hardship Exception Denial and Fee Not Paid
- Misuse of Billing Number- knowingly let another use your billing number
- Abuse of Billing Privileges – billing for deceased beneficiaries (3 or more times), impossible for provider to have rendered services, equipment not available when service that was allegedly provided, or there is a pattern or practice of billing errors
- Failure to Report Changes – another option to revoke if physician (or other Part B provider) fails to report adverse action or change in location
- Non-Compliance with Documentation Requirements – applies to written orders and certifications and requests for payments for items of DMEPOS and clinical laboratory, imaging, and home health services
- Home Health Agency (HHA) Capitalization
- Medicaid Billing Privileges Revoked
- DEA Certificate/State Prescribing Authority Suspension or Revocation
- Improper Prescribing Practices – CMS determines that the physician or eligible professional has a pattern or practice of prescribing Part D drugs that falls into one of the following categories: (i) is abusive or represents a threat to the health and safety of Medicare beneficiaries or both; or (ii) fails to meet Medicare requirements.
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Mr. Laher is an attorney in private practice with Liles Parker, PLLC. We counsel and defend Health Care Providers nationwide on Health Law related issues such as Medicare Audits & Fraud Defense, Medicare Prepayment and Over Payment issues, CMS Suspension and Revocation Actions, Practice Specific Gap Analysis, Compliance Plans, Hippa & Osha mandatory training, and with General Counsel and Compliance Officer Services.