Health Care Lawyers - Ismail Laher Helping Providers Nationwide with (Medicare) Audits and Investigations

Ish Laher and the Attorneys at Liles Parker, PLLC represent Health Care Providers nationwide. We handles Medicare Audits Defense, Medicare Prepayment and Over Payment issues, CMS Suspension and Revocation Actions,, Compliance Plans, Hippa & Osha Mandatory Training

There are 14 Reasons or grounds for Medicare to issue a revocation letter

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

 

  1. Not in Compliance with Medicare Requirements stated in the enrollment application or in the regulations governing enrollment
  2. Excluded/Debarred from Federal Program – provider/supplier, or any owner, managing employee, authorized or delegated official, medical director, supervising physician or “other healthcare personnel”
  3. Felony conviction – ANY felony in last 10 years CMS finds to be detrimental to the Medicare program or its beneficiaries
  4. False or Misleading Information on Application – revocation PLUS fines or imprisonment or both
  5. On-Site Review/Other Reliable Evidence that Requirements Not Met – these are the failed site visits (which usually also list Reason 1 above)
  6. Hardship Exception Denial and Fee Not Paid
  7. Misuse of Billing Number- knowingly let another use your billing number
  8. 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
  9. Failure to Report Changes – another option to revoke if physician (or other Part B provider) fails to report adverse action or change in location
  10. 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
  11. Home Health Agency (HHA) Capitalization
  12. Medicaid Billing Privileges Revoked
  13. DEA Certificate/State Prescribing Authority Suspension or Revocation
  14. 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.

 

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

Medicare Revocation Reason #1 of 14 – Noncompliance with Medicare enrollment application or with enrollment registrations

Medicare Revocation Reasons – #1 of 14 – Noncompliance with Medicare enrollment application or with enrollment registration

 

the certification a provider makes on form 855 is

(start)

“I agree to abide by the Medicare laws, regulations and program instructions that apply to me or to the organization listed in Section 4A of this application.

The Medicare laws, regulations, and program instructions are available through the fee-for-service contractor.

I understand that payment of a claim by Medicare is conditioned upon the claim and the underlying transaction complying with such laws, regulations, and program instructions (including, but not limited to, the Federal anti-kickback statute and the Stark law), and on the supplier’s compliance with all applicable conditions of participation in Medicare.”

(end)

These are found in 42 CFR 424.535(a), and in the Program Integrity Manual, Ch 15, Sec 15.27.2

THIS CAN BE PREVENTED BY TIMELY REPORTING  CHANGES & BY IMPLEMENTING A COMPLIANCE PROGRAM THAT INCLUDE REGULAR CLAIM AUDITING

These grounds are very broad as it encompasses everything from fraud and abuse violations (civil and criminal) to documentation errors, to failing to meet conditions of participation

This reason is often cited in conjunction with other revocation reasons as a backup or alternative.

 

This is the only revocation reason for which a provider can file a corrective action plan (CAP) and is often cited in conjunction with other revocation reasons as a backup or alternative.

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If you have any questions, please feel free to give us a call today. We would be more than happy to assist you in these as well as other compliance-related matters.

Health Care Attorney Ismail Laher

Much of the above was originally  prepared/presented by the acknowledged source or 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