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.
Sign up for The Medical Audits Survival Guide
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.
Much of the above was originally prepared/presented by one or more Liles Parker attorneys for use in one or more of the many webinars, presentations, discussions with clients and and subsequently re purposed for use here by ISH (Attorney Ismail Laher)
Attorneys include Jennifer Papapanagiotou, Michael Cook, Robert Liles, David Parker, Andy Lynch, Paul Weidenfeld, Adam Bird, Lorraine Ater, Les Johnson, Jason Cabell, Leornad Schneider, Richard Pecore, Bethany Meuret, Heidi Kocher, Gloria Frank, Harri Williams, Ismail Laher