Staying Ahead of the Surge in Medicare Revocation Actions

/ Medicare, Medicaid & Private Payor Updates / By

(April 13, 2026): Physicians, home health agencies, and hospices constantly strive to ensure the well-being of their patients. Unfortunately, over the past few years, scores of providers have found themselves at odds with the Centers for Medicare & Medicaid Services (CMS) and its contractors. If you think “It Can’t Happen to Me,” consider this – starting in 2006 and reaching an apex in 2023, CMS has flexed its administrative muscles and greatly expanded the range of regulatory bases that CMS may cite to revoke a provider’s Medicare billing privileges.[1] As of December 31, 2025, more than 7,400 individuals and entities have had their Medicare billing privileges revoked.[2] When an individual or entity gets that dreaded letter from their Medicare Administrative Contractor (MAC) advising the provider that their Medicare billing privileges are being revoked, it’s not just a bureaucratic inconvenience -- it’s a career-altering event. We have seen smart, diligent providers blindsided by Medicare revocation actions. Sometimes these actions are taken for seemingly minor paperwork lapses. Other times, Medicare revocation actions are taken by CMS for issues the providers didn’t even know existed. Unfortunately, the adverse impact of a Medicare revocation action can be long-lasting. In addition to losing their Medicare billing privileges, a health care provider can be barred from re-enrolling in the Medicare program for up to 10 years. In this article, we will briefly discuss the history of Medicare revocation actions, review the current administrative enforcement landscape, and discuss steps you can take to reduce your level of risk.

I. What are Medicare Revocation Actions?

CMS and its contractors are actively revoking the Medicare billing privileges of individuals and entities around the country - Liles Parker

CMS employs a variety of tools to combat fraud and recover improperly disbursed payments through Medicare. Among these tools, CMS administrative and program integrity contractor audits play a critical role in identifying and addressing potential red flags. These audits are designed to investigate fraud, waste, and abuse in both Medicare and Medicaid programs, often beginning with data analysis and involving reviews of medical records and provider claims to detect patterns of improper billing practices.

A. Overview of a Medicare Revocation Action.

CMS has the authority to revoke a provider or supplier’s billing privileges, which is defined as the termination of their ability to bill Medicare.[3] As discussed in the 2023 expansion of CMS’s revocation authorities:

A revocation is designed to safeguard the Medicare program, the Trust Funds, and beneficiaries by removing (and preventing payment to) Medicare providers and suppliers that have engaged in problematic or otherwise non-compliant behavior. When a provider or supplier is revoked, they are generally barred from reenrolling in Medicare for a period of 1 to 10 years. The length of this “reenrollment bar” is predicated upon the severity of the basis of the revocation. The maximum reenrollment bar is typically restricted to egregious acts of misconduct.[4]

CMS may extend the 1 to 10-year revocation up to 3 additional years if it determines that the provider or supplier is attempting to circumvent the reenrollment restrictions by reapplying under a different name, numerical identifier, or business identity.[5]

The effective date of a revocation is typically 30 days after the notice is mailed to the provider or supplier.[6] However, exceptions apply in cases involving exclusion or debarment, felony convictions, license suspensions or revocations, or when a practice location is deemed non-operational. For these exceptions, the effective date aligns with the triggering event, such as a felony conviction.[7]

Additionally, it is important to note that if a provider’s Medicare billing privileges are revoked, the revocation does not directly affect the provider’s ability to submit claims to non-Medicare payors using the provider’s NPI.[8] Nevertheless, a Medicare revocation action is considered a “Formal or Official Action” under Section 1128E of the Social Security Act. As such, it would be reportable to the National Practitioner Data Bank (NPDB).[9] Providers should review their private payor participation agreements to determine if they have an affirmative obligation to report the revocation action to the insurance payor. Ultimately, depending on the specific facts that resulted in revocation, a private payor may initiate action to terminate a provider’s participation agreement.

B. After a Revocation Reenrollment Bar Ends -- Reapplying for Medicare Billing Privileges.

After the reenrollment bar period ends, the provider or supplier may reapply, but their application will be subject to scrutiny, including potential denial on the same grounds that led to the initial revocation. As discussed in this article, CMS’s revocation authorities have dramatically expanded over the past 20 years, and additional modifications are likely. Therefore, providers should keep in mind that future regulatory changes may significantly revise the agency’s regulatory authorities.

II. CMS’s Revocation Authorities Have Greatly Expanded Over the Last 20 Years:

A. Early CMS Revocation Authorities.

In 2003, CMS did not yet have today’s freestanding revocation provisions, now codified at 42 C.F.R. §424.535. As a result, the agency’s enrollment and revocation authorities were quite limited. At that time, the agency’s framework for denying or cutting off Medicare payments and enrollment was based primarily on existing payment-eligibility and enrollment provisions in 42 C.F.R. Part 424, as well as the termination and exclusion authorities outlined in the Medicare Provider Agreement.

B. 2006 Final Rule – First Expansion of CMS’s Revocation Authorities.

In 2006, CMS published a Final Rule[10] titled “Medicare Program -- Requirements for Providers and Suppliers to Establish and Maintain Medicare Enrollment,” that substantially strengthened Medicare’s enrollment enforcement and billing-privileges framework.[11] Most significantly, the 2006 Final Rule established the revocation framework that would later be used to support revocation and denial actions. Although the 2006 Final Rule did not yet contain the comprehensive revocation regime now in place, it did lay the groundwork for CMS’s later expanded enrollment and revocation authorities by:

  • Making enrollment compliance an affirmative condition of billing Medicare. 42 C.F.R. §424.535(a)(1).[12]
  • Revoking the billing privileges of providers and suppliers who are excluded, debarred, or suspended from participating in another federal program. 42 C.F.R. §424.535(a)(2).[13]
  • Requiring timely updates to enrollment information, enabling CMS to act on stale or inaccurate enrollment records. 42 C.F.R. §424.520(b).[14]
  • Authorizing inspections and site visits, including unannounced visits, to verify compliance. 42 C.F.R. §424.535(a)(5); §424.510(d)(8).[15]

C. 2014 Final Rule – Second Expansion of CMS’s Revocation Authorities – The Introduction of Pattern or Practice of Improper Billing.

In 2014, CMS published a Final Rule[16] titled “Medicare Program; Requirements for the Medicare Incentive Reward Program and Provider Enrollment,” that further expanded the agency’s revocation authorities. Among the new enhancements, the Final Rule implemented a regulatory provision permitting CMS to revoke the Medicare billing privileges of a provider or supplier with a “pattern or practice” of submitting claims that fail to meet Medicare requirements.[17] This provision is now one of the primary revocation bases being cited by CMS and its contractors after a provider participates in the Provisional Period of Enhanced Oversight (PPEO) hospice audit initiative. As an example, we recently handled a case in which a provider had their billing privileges revoked under this provision following a PPEO audit. The determination was made following a single review of only 10 claims, five of which were denied. This highlights the practice of revoking billing privileges despite limited claims review. As discussed in the Final Rule, to determine whether a provider has a pattern or practice of submitting improper claims, the agency (and its contractors) considers the following factors:

  1. The percentage of submitted claims that were denied.
  2. The reason(s) for the claim denials.
  3. Whether the provider or supplier has any history of “final adverse actions” (as that term is defined in 42 C.F.R. §424.502.
  4. The length of time over which the pattern has continued.
  5. How long the provider or supplier has been enrolled in Medicare.
  6. Any other information regarding the provider or supplier's specific circumstances that CMS deems relevant to its determination as to whether the provider or supplier has or has not engaged in the pattern or practice described in this paragraph.[18]

The term “pattern or practice” is not explicitly defined in the regulations.[19] CMS has not identified a specific denied-claims percentage threshold that would automatically trigger a revocation. Instead, denied claims can act as a warning or indicator for a provider or supplier. CMS acknowledges that isolated or infrequent billing errors should not result in the revocation of Medicare billing privileges. Additionally, as CMS noted in the preamble of the 2014 Final Rule, if a provider succeeds in fully overturning a claim denial on appeal, it would be excluded from consideration when assessing whether a provider’s Medicare billing privileges should be revoked.[20]

According to CMS, the agency -- not its contractors -- is responsible for determining whether to revoke a provider’s Medicare billing privileges based on “abusive billing patterns.”[21] It is also important to emphasize that the revocation provisions are not limited to claims denials related to medical necessity. The expansion of CMS’s regulatory revocation authorities gave the agency powerful enforcement tools to address compliance deficiencies and improper conduct.

D. 2019 Final Rule – Third Expansion of CMS’s Revocation Authorities.

In September 2019, CMS published a Final Rule titled “Medicare, Medicaid, and Children’s Health Insurance Programs; Program Integrity Enhancements to the Provider Enrollment Process,” which finalized a number of expanded revocation and revalidation denial rules first set out in a Proposed Rule published in March 2016.[22] Enhancements to CMS’s revocation authorities under the 2019 Final Rule included, but were not limited to:

  • Affiliation That Poses an Undue Risk.[23] CMS may revoke the enrollment of a provider or supplier if it determines that the provider or supplier has or had an affiliation under 42 C.F.R. §424.519[24] that poses an undue risk of fraud, waste, or abuse to the Medicare program.[25]
  • Billing from Non-Compliant Location.[26] CMS may revoke a provider's or supplier’s Medicare enrollment or enrollments, even if all of the practice locations associated with a particular enrollment comply with Medicare enrollment requirements, if the provider or supplier billed for services performed at or items furnished from a location that it knew or should have known did not comply with Medicare enrollment requirements.[27]
  • False or Misleading Information.[28] The provider or supplier certified as “true” misleading or false information on the enrollment application to be enrolled or maintain enrollment in the Medicare program. Should the provider or supplier fail to provide true information, it may have its Medicare billing privileges revoked.[29]

For additional information regarding the 2019 Final Rule, please see our previous articles[30] examining the impact of CMS’s expanded revocation authorities.

E. 2023 Final Rule – Fourth Expansion of CMS’s Revocation Authorities.

In November 2023, CMS published a Final Rule titled “Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment Policies; Basic Health Program.”[31] The November 2023 Final Rule greatly expanded the overall scope of CMS’s revocation authorities. Enhancements to the regulations included, but are not limited to:

  • Noncompliance.[32] Under the November 2023 Final Rule, CMS expanded this revocation reason to include instances where the provider or supplier is noncompliant with the enrollment requirements in Title 42. The previous version of 42 C.F.R. §424.535(a)(1) was limited to noncompliance with the provisions of Part 424, Subpart P.[33]
  • False Claims Act Civil Judgments.[34] Under the November 2023 Final Rule, a new basis for revocation was added to cover situations in which a provider, supplier, or certain owners, officers, directors, and/or managing employees have been subject to a civil judgment under the False Claims Act within the last 10 years.[35]
  • Supplier Standard or Condition Violation. Under the November 2023 Final Rule, CMS could not revoke an Independent Diagnostic Testing Facility’s (IDTF’s), Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) supplier’s, Opioid Treatment Program’s (OTP’s), or Home Infusion Therapy (HIT) supplier’s, or Medicare Diabetes Prevention Program (MDPP) supplier’s enrollment based on a violation of any standard or condition in, respectively, §§ 410.33(g),[36] 424.57(c),[37] 424.67(b) or (e),[38] 424.68(c) or (e),[39] or 424.205(b) or (d).[40]

F. 2025 Final Rule – Fifth Expansion of CMS’s Revocation Authorities.

In December 2025, CMS published a Final Rule titled “Medicare and Medicaid Programs; Calendar Year 2026 Home Health Prospective Payment System (HH PPS) Rate Update; Requirements for the HH Quality Reporting Program and the HH Value-Based Purchasing Expanded Model; Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program Updates; DMEPOS Accreditation Requirements; Provider Enrollment; and Other Medicare and Medicaid Policies.”[41] The December 2025 Final Rule significantly expands and clarifies the agency’s authority to revoke Medicare provider and supplier enrollments. Several of the enhancements are described below.

  • Prescribing Authority.[42] Before the December 2025 Final Rule, the language under (a)(13) was unclear, and there was a question of whether a state suspension of a provider’s prescribing authority had to cover all drugs, or if it could be limited to one or more drugs, in order for CMS to revoke the provider’s billing privileges. Given the seriousness of any state suspension or revocation action regarding an individual’s prescribing authority, CMS argued that if a state licensing body suspends or revokes a physician’s ability to prescribe, that was sufficient to warrant the revocation of the provider’s Medicare billing privileges.
  • Abuse of Billing Privileges.[43] CMS expanded the enumerated reasons the agency could revoke a provider's or supplier's billing privileges to include situations in which a beneficiary reports that he/she did not receive the services billed. Therefore, a new reason for revocation was added under 42 C.F.R. §424.535(a)(8), which reads “(d) The beneficiary attests that the item(s) or service(s) identified on the provider's or supplier's claim or claims was not or were not rendered or furnished.”
  • Effective Date of Revocation.[44] In an effort to further support CMS’s ability to prevent improper payments, the agency identified several new grounds and effective dates for retroactive revocations under 42 C.F.R. §424.535(g)(2). These new grounds and effective dates are set out under the newly amended (g)(2).

III. Current List of CMS Revocation Authorities Under 42 C.F.R. §424.535:

As of April 1, 2026, CMS’s revocation authorities under 42 C.F.R. §424.535 include the provisions in the chart below. As the historical overview reflects, since 2003, the agency has regularly revised its revocation authorities, often to address newly identified enrollment risks. Therefore, it is important that providers and suppliers remain current on these provisions. When reviewing these provisions, we recommend that you review the specific requirements and limitations associated with each basis for revocation.

Reason for Revocation Regulatory Citation
Noncompliance. 42 C.F.R. §424.535(a)(1)
Provider or supplier conduct. 42 C.F.R. §424.535(a)(2)
Felonies. 42 C.F.R. §424.535(a)(3)
False or misleading information. 42 C.F.R. §424.535(a)(4)
On-site review. 42 C.F.R. §424.535(a)(5)
Grounds related to provider and supplier screening requirements. 42 C.F.R. §424.535(a)(6)
Misuse of the billing number. 42 C.F.R. §424.535(a)(7)
Abuse of billing privileges. 42 C.F.R. §424.535(a)(8)
Failure to report. 42 C.F.R. §424.535(a)(9)
Failure to document or provide CMS access to information. 42 C.F.R. §424.535(a)(10)
Initial reserve operating funds. 42 C.F.R. §424.535(a)(11)
Other program termination. 42 C.F.R. §424.535(a)(12)
Prescribing authority. 42 C.F.R. §424.535(a)(13)
Improper prescribing practices. 42 C.F.R. §424.535(a)(14)
False Claims Act (FCA). 42 C.F.R. §424.535(a)(15)
Reserved. 42 C.F.R. §424.535(a)(16)
Debt referred to the United States Department of Treasury. 42 C.F.R. §424.535(a)(17)
Revoked under a different name, numerical identifier, or business identity. 42 C.F.R. §424.535(a)(18)
Affiliation that poses an undue risk. 42 C.F.R. §424.535(a)(19)
Billing from non-compliant location. 42 C.F.R. §424.535(a)(20)
Abusive ordering, certifying, referring, or prescribing of Part A or B services, items, or drugs. 42 C.F.R. §424.535(a)(21)
Patient harm. 42 C.F.R. §424.535(a)(22)
Supplier standard or condition violation. 42 C.F.R. §424.535(a)(23)

IV. Appealing Medicare Revocation Actions:

When CMS revokes a provider’s Medicare billing privileges, the provider has the right to appeal the revocation decision.[45] If a provider’s billing privileges are revoked for reasons of “non-compliance,”[46] the provider may have an opportunity to correct the identified deficiencies and submit a Corrective Action Plan (CAP) for the agency’s consideration. A CAP must be submitted within 30 days of the revocation notice and must provide evidence of current compliance. It is important to keep in mind that filing a CAP does not toll a provider’s deadline to appeal the revocation action.

The revocation administrative appeals process includes several levels, each one of which is subject to specific regulations, deadlines, and documentation requirements. Each level is reflected in the chart below:

Level of Appeal Deadline for Filing Appeal Overview of This Level of Appeal
Reconsideration[47] Within 60 Days of the Revocation Notice[48] Reconsideration is the first level of appeal available to providers who challenge the revocation of their Medicare billing privileges. Reconsideration appeals must be submitted within 60 days of the revocation notice to the address cited in the letter.

When filing a reconsideration appeal, it is essential to keep in mind that this is the only level where you will be permitted to submit any documentation and other information that will be needed to challenge the revocation decision. After this level, you will likely be barred from submitting further documentation in support of your arguments for why the revocation action should be withdrawn.

Importantly, if a reconsideration appeal is not requested, CMS deems that as a waiver of all rights to further administrative review.

Pursuant to 42 C.F.R. §424.535(a)(8), the reconsideration appeal will be decided by CMS, as opposed to the Medicare Administrative Contractor.
Administrative Law Judge Hearing[49] Within 60 days of the Reconsideration Decision.[50] Providers unsuccessful at the reconsideration level can appeal the decision to an Administrative Law Judge. Requests for ALJ hearings must be submitted within 60 days of the reconsideration decision. During the hearing, a CMS attorney will likely represent the agency, and the provider can be represented by qualified health law counsel.
Departmental Appeals Board (DAB)
Hearing[51]		 Within 60 Days of the ALJ Decision[52] CMS and providers are both entitled to appeal an ALJ decision to the Departmental Appeals Board. Providers who wish to request a DAB review must do so within 60 days of the ALJ decision and, because the DAB has authority to deny review, should work with experienced healthcare attorneys to prepare their requests.
U.S. District Court
Review.[53]		 Within 60 Days of the Notice of the
DAB Decision[54]		 Any unfavorable decision from the DAB may entitle providers to seek judicial review in federal court. Providers must submit civil actions in the U.S. District Court no later than 60 days after the DAB decision.

V. What Does the Future Look Like for Medicare Revocation Actions?

Over the next year, we anticipate that Medicare revocation actions will remain aggressive, fast-moving, and increasingly tied to audit results, compliance data, site visits, and cross-program enforcement. With the seemingly ever-increasing expansion of CMS’s revocation authority, the agency can flex its administrative muscles like never before. Providers should expect revocation enforcement to be coupled with extended reenrollment bars. Unfortunately, Medicare revocation actions aren’t just a regulatory headache — they can be an existential threat to your practice or clinic. More specifically, Medicare providers should expect to see the following:

  • Significant increases in the use of Medicare revocation actions as administrative enforcement tools 42 C.F.R. § 424.535.
  • Increased use of claims audits and revocations based on a pattern or practice of improper claims, citing an alleged “Abuse of Billing Privileges” under 42 C.F.R. §424.535(a)(8)
  • Expanded collateral consequences of an initial revocation action, leading to additional targets for revocation under the affiliation rules. We are already seeing this impact on owners, managers, and Medical Directors of hospice agencies that are being revoked under the current PPEO audit initiative. For instance, we recently saw an owner’s home health agency have their Medicare billing privileges revoked just months following the revocation of a hospice agency they owned. The home health agency revocation was under the provision for affiliation that poses an undue risk, an example of the expanded collateral consequences of revocation.
  • Revocation appeals are NOT like Medicare administrative claims appeals. Providers have only obtained limited immediate relief through the administrative appeals process. Although there have been a number of cases where an ALJ has overturned a revocation action against a provider or supplier, the record at higher levels of appeal is abysmal.

VI. Conclusion – Responding to a Revocation Action:

In light of CMS’s broad revocation authority and the serious collateral consequences that can follow, providers should take a disciplined, compliance-oriented approach when ordering, certifying and/or performing Medicare services. Every audit, site visit, document request, and investigative inquiry must be treated as a potentially consequential event. Now more than ever, it is essential that all audits be handled with the utmost care, with prompt attention to enrollment, medical necessity, documentation, billing, coding, licensure, ownership, and compliance issues that could later be characterized as grounds for revocation or reenrollment bars. Providers should engage experienced health care counsel early to help navigate audits and investigations, assess risk, preserve privileges, and respond strategically before a routine inquiry becomes a revocation action. The health lawyers at Liles Parker have extensive experience representing individuals and entities in Medicare revocation actions. Are your claims being audited? Have your Medicare billing privileges been revoked? Click here to schedule an initial complimentary consultation with Liles Parker.

Ashley Morgan - Partner - Senior Health care attorney - Liles Parker
Christin Thompson
Michael Tobin Associate Attorney - Liles Parker - 150 x 150
Michael Tobin
| Michael Tobin
Ashley Morgan and Michael Tobin are attorneys with the health law firm, Liles Parker. They are both experienced healthcare attorneys and hold certifications as a Certified Professional Coder (CPC). Their practices are concentrated exclusively on healthcare law and particularly on the appeal of claim denials, regulatory appeals, and compliance planning.

Both Ashley and Michael have defended individuals and entities in Medicare billing privilege revocation cases. Are you facing a Medicare revocation action? Click here to schedule a free consultation with Ashley or Michael.

+1 (800) 475-1906   |   +1 (202) 298-8750
  • [1] 42 C.F.R. §424.535.
  • [2] To be clear, this database lists providers and suppliers who are under an active reenrollment bar. Moreover, the list is restricted to: (1) Providers and suppliers with an active reenrollment bar in effect, and (2) the provider’s or supplier’s first-level appeal has been exhausted or not filed. To review the list, see CMS’s website, “Revoked Medicare Providers and Suppliers.” https://data.cms.gov/provider-characteristics/medicare-provider-supplier-enrollment/revoked-medicare-providers-and-suppliers
  • [3] 42 C.F.R. §502.
  • [4] CMS Summary of the Final Rule provided under 88 Fed. Reg. 78818 (November 16, 2023).
  • [5] 42 C.F.R. §424.535(c)(2)(i).
  • [6] 42 C.F.R. §424.535(g)(1).
  • [7] 42 C.F.R. §424.535(g)(2)(ii).
  • [8] Medicare Program Integrity Manual, Chapter 10, §10.4.7.1 – Revocations – Background and General Requirements.
  • [9] National Practitioner Data Bank (NPDB) – Reportable Actions. https://www.npdb.hrsa.gov/hcorg/whatYouMustReportToTheDataBank.jsp
  • [10] See Final Rule titled "Medicare Program; Requirements for Providers and Suppliers to Establish and Maintain Medicare Enrollment" 71 Fed. Reg. 20754 (April 21, 2006).
  • [11] The 2006 Final Rule titled “Medicare Program; Requirements for Providers and Suppliers To Establish and Maintain Medicare Enrollment,” 71 Fed. Reg. 20754 (April 21, 2006), introduced a number of regulatory enhancements to CMS’s revocation authorities.
  • [12] 71 Fed. Reg. 20754, 20779 (April 21, 2006).
  • [13] 71 Fed. Reg. 20754, 20778-20779 (April 21, 2006).
  • [14] 71 Fed. Reg. 20754, 20778 (April 21, 2006).
  • [15] 71 Fed. Reg. 20754, 20777 (April 21, 2006).
  • [16] In 2013, CMS published a Proposed Rule titled “Medicare Program; Requirements for the Medicare Incentive Reward Program and Provider Enrollment.” 78 Fed. Reg. 25013 (April 29, 2013). In December 2014, CMS published a Final Rule titled “Medicare Program; Requirements for the Medicare Incentive Reward Program and Provider Enrollment.” 79 Fed. Reg. 72500 (December 5, 2014). The December 2014 Final Rule added several provider-enrollment revocation tools.
  • [17] Prior to this enhancement, 42 C.F.R. §424.535(a)(8) only permitted CMS to revoke a provider’s Medicare billing privileges if the provider submitted a claim that could not have been furnished to a specific individual on the date of service.
  • [18] 79 Fed. Reg. 72500, 72532 (December 5, 2014).
  • [19] 79 Fed. Reg. 72500, 75212 (December 5, 2014). CMS explicitly states that it did not define "pattern or practice" in the regulation. Instead, the agency explains that determinations would be made on a case-by-case basis, considering various factors, and that a rigid definition would not allow for necessary flexibility in enforcement.
  • [20] 79 Fed. Reg. 72500, 75212 (December 5, 2014). The preamble clarifies that CMS did not set a specific percentage or numeric threshold of denied claims that would automatically trigger revocation. The agency emphasized that such a threshold would be arbitrary and that revocation decisions would be based on the totality of circumstances.
  • [21] Despite CMS’s statement to the contrary, the record suggests that contractors play a more significant role in recommending a revocation action than the agency first suggested in 2014. A review of Administrative Law Judge (ALJ) decisions in Medicare revocation appeals cases suggests that the initial decision to revoke a provider’s billing privileges is made by the CMS contractor.
  • [22] A Proposed Rule titled “Medicare, Medicaid, and Children’s Health Insurance Programs; Program Integrity Enhancements to the Provider Enrollment Process,” 81 Fed. Reg. 10,720 (March 1, 2016) was subsequently followed by the associated Final Rule titled “Medicare, Medicaid, and Children’s Health Insurance Programs; Program Integrity Enhancements to the Provider Enrollment Process.” 84 Fed. Reg. 47794 (September 10, 2019).
  • [23] 42 C.F.R. § 424.535(a)(19).
  • [24] 42 C.F.R. § 424.519 sets out the information that an enrolling or revalidating provider or supplier must disclose to CMS in terms of affiliations.
  • [25] 84 Fed. Reg. 47794, 47813-47815 (September 10, 2019).
  • [26] 42 C.F.R. § 424.535(a)(19).
  • [27] 84 Fed. Reg. 47794, 47815 (September 10, 2019).
  • [28] 42 C.F.R. § 424.535(a)(4).
  • [29] 84 Fed. Reg. 47794, 47816 (September 10, 2019).
  • [30] Please see our article titled “Responding to a Medicare Revocation Action Effective Prior to November 4, 2019,” (March 9, 2020). Also see our article titled “Medicare Revocation Action: Steps for Avoiding and Appealing” (September 16, 2014).
  • [31] The associated Proposed Rule titled “Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment” was published in August 2023. See 88 Fed. Reg. 52262 (August 7, 2023). The Final Rule, titled “Medicare and Medicaid Programs; CY 2024 Payment Policies Under the Physician Fee Schedule and Other Changes to Part B Payment and Coverage Policies; Medicare Shared Savings Program Requirements; Medicare Advantage; Medicare and Medicaid Provider and Supplier Enrollment Policies, and Basic Health Program,” was published in November 2023. See 88 Fed. Reg. 78818 (Nov. 16, 2023).
  • [32] 42 C.F.R. § 424.535(a)(1).
  • [33] 88 Fed. Reg. 78818, 79500 (November 23, 2023).
  • [34] 42 C.F.R. § 424.535(a)(15).
  • [35] 88 Fed. Reg. 78818, 79500 (November 23, 2023).
  • [36] 42 C.F.R. §410.33 covers “Independent Diagnostic Testing Facilities (IDTFs).” It discusses coverage and payment for diagnostic procedures, limitations on supervising physicians, tests that may be performed by nonphysician personnel, requirements for ordering tests, and other applicable IDTF certification standards.
  • [37] 42 C.F.R. §424.47 covers special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges.
  • [38] 42 C.F.R. §424.67(b) covers the specific requirements and standards for the enrollment of an Opioid Treatment Program. 42 C.F.R. §424.67(e) covers an Opioid Treatment Program’s continued compliance, standards, and reasons for revocation.
  • [39] 42 C.F.R. §424.68(c) covers the specific requirements for enrollment applicable to home infusion therapy suppliers. 42 C.F.R. §424.68(e) covers a home infusion therapy’s continued compliance, standards, and reasons for revocation.
  • [40] 42 C.F.R. §424.205(b) covers the conditions required for an entity to enroll in Medicare as a “Medicare Diabetes Prevention Program (MDPP) supplier. Pursuant to 42 C.F.R. §424.205(d), to furnish MDPP services to a Medicare beneficiary, a “coach” (an individual who furnishes MDPP services on behalf of an MDPP supplier as an employee, contractor, or volunteer) must meet the requirements set out under this provision.
  • [41] The associated Proposed Rule titled "Medicare and Medicaid Programs; Calendar Year 2026 Home Health Prospective Payment System (HH PPS) Rate Update; Requirements for the HH Quality Reporting Program and the HH Value-Based Purchasing Expanded Model; Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program Updates; DMEPOS Accreditation Requirements; Provider Enrollment; and Other Medicare and Medicaid Policies" was published in July 2025. 90 Fed. Reg. 29108 (July 2, 2025)). The Final Rule, titled “Medicare and Medicaid Programs; Calendar Year 2026 Home Health Prospective Payment System (HH PPS) Rate Update; Requirements for the HH Quality Reporting Program and the HH Value-Based Purchasing Expanded Model; Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program Updates; DMEPOS Accreditation Requirements; Provider Enrollment; and Other Medicare and Medicaid Policies” was published in December 2025. 90 Fed. Reg. 55342 (Dec. 2, 2025).
  • [42] 42 C.F.R. §424.535(a)(13).
  • [43] 42 C.F.R. §424.535(a)(14).
  • [44] 42 C.F.R. §424.535(g).
  • [45] 42 U.S.C. 1395cc(j) authorizes the Secretary, HHS, to establish a process for administrative and judicial review of revocation of a provider’s billing privileges.
  • [46] 42 CFR 424.535(a)(1)
  • [47] 42 C.F.R. §498.22(b)(3). Also see 42 C.F.R. §424.545.
  • [48] 42 C.F.R. §498.22(b)(3). The date of receipt will be presumed to be 5 days after the date on the notice unless there is a showing that it was, in fact, received earlier or later.
  • [49] 42 C.F.R. §498.40(a)(1).
  • [50] 42 C.F.R. §498.40(a)(2).
  • [51] 42 C.F.R. §498.82(a)(1).
  • [52] 42 C.F.R. §498.82(a)(2).
  • [53] 42 C.F.R. §498.5(l)(1).
  • [54] 42 C.F.R. §498.95(a).