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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

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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 – Eac one is discussed in detail in a separate posts

September 17, 2015 //  by AdminL

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.

 

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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.

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

Category: Education, General, Revocation IssuesTag: Education, Guidance, Revocation

Previous Post: « Medicare Revocation Reason #1 of 14 – Noncompliance with Medicare enrollment application or with enrollment registrations
Next Post: Centers for Medicare and Medicaid Services (CMS) now gives Providers and suppliers only 45 calendar days to submit and comply with any ADR’s (Additional Document Requests) from Medicare Administrative Contractors (MAC) and Zone Program Integrity Contractors (ZPIC) »

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Recent Posts

  • CMS has the authority to revoke if the the provider or supplier has a pattern of submitting claims that fail to meet Medicare requirements.
  • As required by section 13402(e)(4) of the HITECH Act, the Secretary must post a list of breaches of unsecured protected health information affecting 500 or more individuals. The following breaches have been reported to the Secretary:
  • The Physicians Advocacy Institute (PAI) and American College of Emergency Physicians (ACEP) have published a Toolkit for Physicians Facing Medical Audits.
  • Doctors and Providers in the news
  • Medicare Revocation Reason #4 of 14 – Providing False or Misleading Information on Application
  • Medicare Revocation Reason #3 of 14 – can be triggered by a Felony conviction in last 10 years
  • Protected: Medicare Revocation Reason #2 of 14 continued – A related issue is employing or contracting with persons or entities excluded from Federal Health Care programs
  • Medicare Revocation Reason #2 of 14 – Excluded or Debarred from Federal Program:
  • State MFCUs (Medicaid fraud Control Units) play the primary role for Medicaid in the investigation and prosecution of provider fraud and patient abuse or neglect in health care facilities
  • Centers for Medicare and Medicaid Services (CMS) now gives Providers and suppliers only 45 calendar days to submit and comply with any ADR’s (Additional Document Requests) from Medicare Administrative Contractors (MAC) and Zone Program Integrity Contractors (ZPIC)
  • There are 14 Reasons or grounds for Medicare to issue a revocation letter
  • Medicare Revocation Reason #1 of 14 – Noncompliance with Medicare enrollment application or with enrollment registrations
  • Official HHS OCR Guidance on conducting a Hippa risk analysis
  • $750,000 HIPAA settlement emphasizes the importance of risk analysis and device and media control policies with respect to privacy regulations
  • Protected: The Dreaded Revocation Letter is simply a form letter generated by your Medicare contractor
  • Protected: Medicare Enrolled Providers MUST be able to prove delivery before their reporting deadline passes
  • Protected: Medicare requires you to report within 30 days any Adverse Legal Actions to EACH TIN/EIN OR NPI they have
  • Medicare requires you to report within 30 days any Adverse Legal Action such as certain defined Revocations or Suspensions
  • Medicare requires you to report within 30 days any Adverse Legal Action such as certain types of convictions
  • Provider must re validate Medicare enrollment upon request
  • ANY change to information on the Medicare CMS-855 enrollment form must be reported.
  • Enhanced Medicare Screening Requirements now require fingerprint-based background checks for certain new enrollees – HHA’s and DME’s,
  • Enhanced Medicare Screening Requirements now require site visits for certain new enrollees,
  • Failing to Report a Final Adverse Legal Action is another is a very fast way to Losing Your Medicare Number
  • Not taking even minor licensing or other regulatory actions seriously is another way to losing your Medicare Number
  • Employing Excluded Persons/Failing to Properly and Completely Screen Employees, Contractors, Owners & Managers is another way to losing your medicare number
  • Failing to Keep Necessary Paperwork to Support Payment for Services is another way to losing your Medicare Number
  • Haphazard billing/failing to self audit is another way to lose your Medicare number
  • Billing for Deceased Beneficiaries is another is a very fast way to Losing Your Medicare Number
  • Failing to Report a Final Adverse Legal Action is another is a very fast way to Losing Your Medicare Number
  • Failing to Keep Regular Business Hours/Proper Signage is another fast way to losing your Medicare number
  • Failing to Report a Change of Location is a very fast way to Losing Your Medicare Number
  • Suspension Actions – Provider can continue seeing Medicare patient but Monies are kept in escrow
  • Protected: Medicare claims administration contractors improperly paid an estimated $29.6 billion during the Federal fiscal year 2012 reporting period.
  • Oct 15 is switch over to EMV chip technology credit cards – Health Care Providers using the old NFC Technology will RETAIN liability in the event of Fraud
  • CMS has directed its contractors to focus on preventing the payment of improper claims.
  • This website is provided as general information only. It does not constitute legal advice and should not be used as a substitute for seeking legal counsel.
  • Private payors are participating in Health Care Fraud Working Group meetings with CMS representatives and other federal agents.
  • Revocation Actions – Typically this for a Failure to Co-operate, or to meet core requirements, or to notify a change of address
  • Suspension Actions – now under Under the ACA, CMS may now suspend payments based on a “credible allegation of fraud” unless there is “good cause” not to suspend payments.
  • Protected: Post Payment Review Audits are serious and can result in extrapolated damages.
  • Protected: Post Payment Review – Primary Sources of an Audit.
  • Pre Payment & Post Payment Review – Typical Audit issues
  • Pre Payment review – What is a good Provider response?
  • Protected: Pre Payment Reviews – are there any DISADVANTAGES to NOT receiving Notice
  • Protected: Pre Payment Reviews – Preparation is a great benefit of Advance Notice
  • Protected: Pre Payment Reviews – Notice to Provider is REQUIRED but …???!@!!
  • Protected: Pre Payment Reviews – IS NOTICE PROVIDED?
  • Protected: Who conducts prepayment reviews?
  • CMS has directed its contractors to focus on preventing the payment of improper claims.

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