South Florida Hospital News
Saturday July 11, 2020

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October 2015 - Volume 12 - Issue 4

CMS Steps Up Medicare Revocation Actions

The Centers for Medicare and Medicaid Services ("CMS") published a final rule, effective February 3, 2015, that drastically expanded CMS's ability to revoke a provider's Medicare billing privileges ("Final Rule"). This Final Rule has proved to be a serious threat to providers as CMS uses this new authority to strip more providers of their Medicare billing privileges and provider agreements.

Even before the Final Rule, CMS had a long list of reasons it could rely on to revoke a provider's billing privileges. However, in the past, CMS may have conducted an audit of the suspect claims and given the provider a chance to explain or correct the claims. But now, CMS appears to favor using revocation to rid the Medicare program of providers it considered to be "bad actors." Recently, CMS has been using more frequently one of the long standing reasons for revocation, that is, when CMS believes that a provider has "abused its billing privileges." According to the applicable regulation, such "abuse" can occur when a provider submits a claim for services that could not have not been furnished to a specific individual on a date of service, like, for instance, claims submitted for dates of service after a beneficiary is deceased or when the physician is not in the state or country. Additional bases for revocation added by the Final Rule, include when CMS determines that a provider has a "pattern or practice" of denied claims. The prospect of a revocation based on an abuse of billing privileges or a pattern of denied claims is particularly troublesome because these standards are both vague and broad. Also, CMS's recent use of data mining and its access to records of other state and federal agencies has allowed CMS to identify suspect situations that in the past may not have come to its attention.
The message to providers is clear – providers will be held accountable for all claims they submit to the Medicare program. The provider is expected to know the Medicare billing requirements. If there are billing, coding, or documentation problems with the claims causing them to fail to meet the Medicare regulations, such claims could form the basis for a revocation action. To avoid revocation, providers must ensure that each claim meets the requirements by educating themselves and their billing personnel about proper billing for services provided to Medicare beneficiaries. Providers should consider engaging competent healthcare consultants to advise them about the correct billing and coding processes and to conduct audits of claims to identify any problems. Any provider who is placed on prepayment review or receives a notice of an audit or investigation related to Medicare claims should be especially vigilant in assessing its billing practices, identifying any problems and correcting such problems. Providers who receive an increased number of denials or requests for additional information may be on CMS's "radar screen" and should intensify efforts to review their claims.
Moreover, as if losing your Medicare billing privileges is not enough, the Medicaid program in Florida may take action to suspend or terminate your Medicaid provider number if your Medicare billing privileges are revoked. Making the situation for a revoked provider even worse, there is a Florida law that prevents professional licensing boards, such as the Board of Medicine, from renewing certain providers' licenses if they have been terminated "for cause" from the Medicaid program. This Draconian result is especially sad when one considers that the situation may have been caused by a pattern of mistakes that could have been prevented had the provider been more knowledgeable and diligent in its billing practices.

 Anne Novick Branan is a health law attorney and Of Counsel for the Fort Lauderdale office of the statewide law firm Broad and Cassel. She can be reached at or (954) 764-7060.

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