Liles Parker PLLC
(202) 298-8750 (800) 475-1906
Washington, DC | Houston, TX
Baton Rouge, LA

We Defend Healthcare Providers Nationwide in Audits & Investigations.

What is a Medicare Deactivation of Your Billing Privileges?

January 10, 2021 by  
Filed under

Download PDF

A Medicare participant’s billing privileges can be terminated or revoked for many reasons. [1]  Unfortunately, if the Centers for Medicare and Medicaid Services (CMS) revokes the Medicare billing privileges of a participating provider or supplier, the revocation action may be in effect for up to 10 years.  In comparison, if a provider’s Medicare billing privileges are deactivated, it is often more straightforward to seek reactivation of an entity’s billing privileges.  An overview of the Medicare deactivation process and several considerations when seeking Medicare reactivation of your billing privileges are set out below.

I.  What is a Medicare Deactivation Action?

The term “Deactivate” is expressly defined by regulation to mean that a “provider or supplier’s billing privileges were stopped, but can be restored upon the submission of updated information.” [2]   A participating health care provider or supplier typically runs the risk of having its Medicare number deactivated if one of the following occurs:

“(1) The provider or supplier does not submit any Medicare claims for 12 consecutive calendar months. The 12 month period will begin the 1st day of the 1st month without a claims submission through the last day of the 12th month without a submitted claim. [3]

(2) The provider or supplier does not report a change to the information supplied on the enrollment application within 90 calendar days of when the change occurred. Changes that must be reported include, but are not limited to, a change in practice location, a change of any managing employee, and a change in billing services. A change in ownership or control must be reported within 30 calendar days as specified in §§ 424.520(b) and 424.550(b). [4]

(3) The provider or supplier does not furnish complete and accurate information and all supporting documentation within 90 calendar days of receipt of notification from CMS to submit an enrollment application and supporting documentation, or resubmit and certify to the accuracy of its enrollment information.” [5]

II.  What is the Effect of the Deactivation of a Provider’s Billing Privileges?

Essentially, when a Medicare number is deactivated, the provider’s (or supplier’s) billing privileges are temporarily stopped. The deactivation of billing privileges is intended to protect the Medicare Trust Fund from abuse and keep a specific billing number from being misused.  Importantly, the deactivation of a provider’s (or supplier’s) Medicare billing privileges does not have any effect on its participation agreement or associated conditions of participation. [6]

III.  Real-Life Examples of Medicare Deactivation Actions:

42 C.F.R. § 424.540(a)(1).   Did not submit any Medicare claims for 12 consecutive months.  When considering this basis for Medicare deactivation, it would be completely reasonable for you to ask “Why should it matter if I haven’t submitted any Medicare claims for this period?”  Good question.  The purpose of this particular provision is “to prevent situations in which unused, idle Medicare billing numbers could be accessed by individuals and entities to submit false claims.” [7]  Only a handful of published administrative decisions address this reason for deactivation.

In one California case, an Oncologist’s Medicare billing privileges were deactivated because the physician had allegedly not submitted any claims to Medicare for 12 consecutive months or more.  The physician appealed the action before an Administrative Law Judge (ALJ) and lost.  He subsequently appealed the ALJ’s decision to the Departmental Appeals Board (DAB).

As with all of the (a)(1) Medicare deactivation actions we reviewed, there were factual disputes related to the submission of reactivation requests and associated documentation discussed throughout the record in this case.  While a resolution of these factual disputes is typically important to determine when reactivation should have occurred, the more interesting aspect of this DAB’s discussion of what, if any, appeal rights a provider has when it comes to challenging a Medicare deactivation action.  As the DAB noted, 42 C.F.R. §424.545 sets out the appeal rights of Medicare providers and suppliers.  While a prospective provider or supplier whose enrollment has been revoked may appeal that decision under 42 C.F.R. §424.545(a), no such rights are available in a Medicare deactivation action.  In fact, as 42 C.F.R. §424.545(b) expressly states:

 “(b) A provider or supplier whose billing privileges are deactivated may file a rebuttal in accordance with § 405.374 of this chapter.”

As 42 C.F.R. §405.374 discusses, an opportunity to file a rebuttal is really nothing more than the opportunity to submit a statement in support of your position.  The bottom line is that there is no regulation that affords appeal rights to a provider to challenge a Medicare contractor’s deactivation of the provider’s billing privileges.[8]

42 C.F.R. § 424.540(a)(1).  Did not report a change in enrollment application information, change in ownership, or a change of practice location within the specified timeframes. In a New Jersey case involving a medical group, the group was advised by its Medicare Administrative Contractor (MAC) that it needed to file a CMS-855B change request because the MAC had learned from the Social Security Administration that one of the practice’s owners had recently died.  The letter also informed the medical group that the changes request must be submitted “within 90 calendar days of the date of [the] letter in order to avoid deactivation of Medicare billing privileges.”

The medical group failed to respond within 90 days.  When it finally did respond, the CMS-855B change request deleted five partners from the medical groups enrollment record, not merely the one physician who had recently died. The MAC subsequently approved the medical group Medicare reactivation request but there was a three week “gap” in billing privileges between the deactivation date and the reactivation date (caused by the late submission of documentation by the medical group).  The medical group then challenged the dates used by the MAC in an effort to get the three week gap erased.  They lost.

42 C.F.R. § 424.540(a)(3).  Did not furnish complete and accurate information and all supporting documentation within 90 calendar days of receipt of notification from CMS.   Most of the Medicare deactivation actions taken based on (a)(3) are the result of a participating provider or supplier failing to properly respond to a revalidation request from a MAC.  As you may recall, to maintain its Medicare billing privileges, an enrolled provider or supplier must “revalidate” their enrollment every five years.  This is accomplished by resubmitting and recertifying their Medicare enrollment information.[9]  Should a provider or supplier fail to submit the information requested within 90 calendar days, CMS may deactivate the entity’s Medicare billing privileges.

In a recent case out of Michigan, an oncology clinic failed to submit its revalidation paperwork in a timely fashion and its Medicare billing privileges were deactivated under reason (a)(3).  By the time a proper reactivation requires was filed and approved, there was a gap in the provider’s billing privileges.  Once again, the provider appealed the dates at issue in an effort to “remove the gap.”  The ALJ sustained the agency’s deactivation action noting that he did not have the authority to review deactivation decisions.  The ALJ further stated that he:

“not have authority to provide equitable relief. . . based on principles of fairness.” 

IV.  What is a Medicare Reactivation Action?

When the Medicare number of a participating provider or supplier has been deactivated because of one of the reasons set out under 42 C.F.R. § 424.540(a)(1) to (a)(3), action may be taken to reactivate the entity’s billing privileges.  The Medicare reactivation requirements are set out under 42 C.F.R. § 424.540(b)(1) to (b)(3):

“(1) In order for a deactivated provider or supplier to reactivate its Medicare billing privileges, the provider or supplier must recertify that its enrollment information currently on file with Medicare is correct and furnish any missing information as appropriate. [10]

(2) Notwithstanding paragraph (b)(1) of this section, CMS may, for any reason, require a deactivated provider or supplier to, as a prerequisite for reactivating its billing privileges, submit a complete Form CMS-855 application. [11]

(3) Except as provided in paragraph (b)(3)(i) of this section, reactivation of Medicare billing privileges does not require a new certification of the provider or supplier by the State survey agency or the establishment of a new provider agreement.  [12]

(i) An HHA whose Medicare billing privileges are deactivated under the provisions found at paragraph (a) of this section must obtain an initial State survey or accreditation by an approved accreditation organization before its Medicare billing privileges can be reactivated.”  [13]

V.  Responding to the Deactivation of Your Medicare Billing Privileges:

While responding to a Medicare deactivation action is significantly less complex than handling a Medicare revocation action, we recommend that you obtain the assistance of a qualified health law attorney before attempting to challenge a Medicare deactivation case or the effective of a Medicare reactivation decision issued by a MAC.

Liles Parker attorneys have extensive experience representing participating providers and suppliers nationwide in Medicare deactivation actions.  We can help.  Give us a call for a free consultation.  1 (800) 475-1906.

Liles Parker attorneys can assist you with your Medicare Reactivation Request

[1] For an overview of the reasons that a participating provider’s Medicare billing privileges, please see our page titled “42 CFR Sec. 424.535(a) Medicare Revocation Actions — Your Medicare Billing Privileges Can be Revoked for a Host of New Reasons. Are You Facing a Medicare Revocation Action? If so, You Must Act Fast to Preserve Your Appeal Rights.”

[2] 42 C.F.R. § 424.502.

[3] 42 C.F.R. § 424.540(a)(1).

[4] 42 C.F.R. § 424.540(a)(2).

[5] 42 C.F.R. § 424.540(a)(3).

[6] 42 C.F.R. § 424.540(c).

[7] Final Rule, 77 Fed. Reg. 29,002, 29,010 (May 16, 2012).

[8] See also Arkady B. Stern, M.D., DAB No. 2417, at 3 n.4 (2011) (Petitioner argues on appeal that deactivation was improper, but Board “does not have authority to review” deactivation under circumstances of this case, citing 42 C.F.R. §§ 424.545(b) and 498.3(b)); Andrew J. Elliott, M.D., DAB No. 2334, at 4 n.4 (2010) (Board “does not have authority to review” a deactivation).

[9] 42 C.F.R. § 424.515.

[10] 42 C.F.R. § 424.540(b)(1).

[11] 42 C.F.R. § 424.540(b)(2).

[12] 42 C.F.R. § 424.540(b)(3).

[13] 42 C.F.R. § 424.540(b)(3)(i).

 

Medicare Revocation Actions Related to Telemedicine Rising!

Download PDF

Medicare Revocation Actions are Increasing Around the Country(September 25, 2020):  In recent years, many individuals (especially younger members of our work force) have embraced the chance to supplement their income through short-term engagements in the “gig economy.”  Notably, both professionals and non-professionals alike have found flexible, part-time opportunities online, allowing them to work remotely as independent contractors.  A number of physicians, nurse practitioners and physician assistants have taken advantage of the chance to participate in the gig economy, working virtually and providing telemedicine services for patients.  Unfortunately, many of these licensed professionals have conducted little or no due diligence into the companies engaging them to conduct evaluations by phone, video or asynchronously.  In some cases, the company engaging these licensed professionals to provide telemedicine evaluations has been alleged to have illegally funneled prescriptions issued by these professionals to third-party durable medical equipment (DME) suppliers.  Associated physicians, nurse practitioners and physician assistants (collectively referred to as “Telemedicine Providers”) have then found themselves subject to administrative sanctions, civil liability, and, in some case, criminal prosecution.  This article examines the Medicare revocation actions that have resulted from a Telemedicine Provider’s failure to provide access to documentation related to telemedicine services that are currently being pursued by Medicare Administrative Contractors (MACs) around the country.

I.  Overview of Statutory and Regulatory Concerns When Providing Telemedicine Evaluations:

With the advent of COVID, both governmental and private payors alike have supported the expansion of telehealth / telemedicine services.  Coverage and payment rules have been expanded by most payors and patients have welcomed the opportunity to be evaluated remotely by their caregiver.  Generally, the current wave of telemedicine related enforcement actions has been unrelated to the coverage expansions resulting from the spread of COVID.  The vast majority of Medicare revocation actions associated with improper telemedicine business practices have been related to pre-COVID conduct.   An overview of these improper telemedicine cases is provided below:

  • Intermediary marketing companies.  Over the last few years, licensed providers with prescribing authority have been actively recruited by an intermediary company[1] OR have responded to an online advertisement seeking to hire physicians, nurse practitioners or physician assistants to perform remote telemedicine evaluations. These companies essentially serve as middlemen – they are not typically participating providers or suppliers in the Medicare program.
  • Lists of beneficiaries to be evaluated remotely are assembled by the intermediary marketing companies. Using a variety of patient recruiting and screening methods, representatives of the intermediary marketing company will work to assemble a list of prospective beneficiaries who have expressed an interest in being evaluated for DME.  The intermediary marketing company then provides these beneficiary lists to Telemedicine Providers who have been engaged to conduct remote assessments and evaluations[2] of these individuals. After completing an evaluation, the Telemedicine Provider then decides whether it is medically necessary and appropriate to order DME for the beneficiary. Typically, the licensed providers have been paid a fixed amount of $25 — $30 for each telemedicine evaluation conducted.
  • Beneficiaries have no control of where an order or prescription is referred.  In the cases we have handled, orders for DME have NOT been issued to a supplier, pharmacy or testing laboratory selected by the patient.  Instead, the order has been directed by the intermediary marketing company to a particular supplier, pharmacy or testing laboratory with whom the company has a business relationship.[3]
  • Unified Program Integrity Contractors (UPICs) are using data mining to identify potentially fraudulent telemedicine business relationships.  Through an analysis of billing data, UPICs have noted that some DME suppliers have billed Medicare for items based on orders issued by a physician, nurse practitioner or physician assistant who did NOT bill Medicare for an associated Evaluation and Management (E/M) service, either directly or through an appropriate reassignment relationship.
  • UPIC requests for medical records have often gone unanswered or unfulfilled.  Both UPICs and a variety of state and federal law enforcement agencies around the country have been investigating questionable telemedicine related business relationships.  One of the essential steps in investigating the propriety of these claims has included an assessment of the beneficiary’s medical records, along with the telemedicine evaluation conducted.  These medical records and intake documents are often maintained by the intermediary marketing company and have not been downloaded or maintained by the ordering physician, nurse practitioner or physician assistant. Moreover, the contracts between the parties often prohibit the physician from retaining copies of documents. In several cases we have handled, the licensed provider’s relationship with the intermediary marketing company was terminated long ago and the provider no longer has access to the beneficiary records now being requested.
  • Telemedicine providers are often unaware that a marketing company is engaging in illegal kickback activities.  Licensed providers are not usually privy to the terms of any business relationship between an intermediary marketing company and an associated DME supplier.  Both UPICs and law enforcement agencies around the country are investigating these telemedicine related business relationships.

II. Medicare Revocation Actions Based on a Provider’s Failure to Provide Access to Documents are Being Pursued by CMS Around the Country:

The failure to respond or comply with a UPIC request for records is one of the many bases[4] that CMS may assert to revoke a provider’s enrollment in the Medicare program, along with any corresponding provider agreement. As provided by 42 C.F.R. § 424.535(a)(10):

Ҥ 424.535 РRevocation of enrollment in the Medicare program.

(10) Failure to document or provide CMS access to documentation. (i) The provider or supplier did not comply with the documentation or CMS access requirements specified in § 424.516(f). . .”

As 42 C.F.R. § 424.516(f) provides:

  • 424.516 – Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare program.

“(f) Maintaining and providing access to documentation. (1)(i) A provider or a supplier that furnishes covered ordered, certified, referred, or prescribed Part A or B services, items or drugs is required to –

(A) Maintain documentation (as described in paragraph (f)(1)(ii) of this section) for 7 years from the date of service; and

(B) Upon the request of CMS or a Medicare contractor, to provide access to that documentation (as described in paragraph (f)(1)(ii) of this section).

(ii) The documentation includes written and electronic documents (including the NPI of the physician or, when permitted, other eligible professional who ordered, certified, referred, or prescribed the Part A or B service, item, or drug) relating to written orders, certifications, referrals, prescriptions, and requests for payments for Part A or B services, items or drugs.

(2)(i) A physician or, when permitted, an eligible professional who orders, certifies, refers, or prescribes Part A or B services, items or drugs is required to

(A) Maintain documentation (as described in paragraph (f)(2)(ii) of this section) for 7 years from the date of the service; and

(B) Upon request of CMS or a Medicare contractor, to provide access to that documentation (as described in paragraph (f)(2)(ii) of this section).

(ii) The documentation includes written and electronic documents (including the NPI of the physician or, when permitted, other eligible professional who ordered, certified, referred, or prescribed the Part A or B service, item, or drug) relating to written orders, certifications, referrals, prescriptions or requests for payments for Part A or B services, items, or drugs.” (emphasis added).

III.  Medicare Revocation Actions for the Failure to Provide Medical Records Have Typically Sought a 10-Year Re-Enrollment Bar.

CMS extended the maximum re-enrollment bar that can be applied after a revocation from three years to ten years through a Final Rule, which was published on September 10, 2019 and became effective November 4, 2019.[5]  Although a 10-year re-enrollment bar is supposed to be reserved for cases involving serious misconduct, CMS has been actively seeking a 10-year re-enrollment bar in cases where the basis for exclusion is the failure to provide access to documentation.[6]

  • What is the impact of a Medicare revocation action?  The imposition of a 10-year re-enrollment bar can effectively destroy a health care provider’s practice.  Moreover, it will likely limit a provider’s employment options.  Additional potential consequences of having your Medicare enrollment revoked are discussed below.
  • Depending on the facts, the role you played in a telemedicine fraud case may result in a referral to the U.S. Department of Justice (DOJ) for investigation and possible prosecution. Since 1994, CMS has participated in an interagency agreement with the DOJ which allows CMS program integrity contractors (in this case, UPICs) to send health care fraud referrals directly to the DOJ without having to first route the referral through the Office of Inspector General (OIG).  Your involvement in a telemedicine related fraud case will be carefully evaluated.  For instance, did you actually conduct evaluations by phone, video or asynchronously OR did you perform an evaluation based solely on the medical information and intake documents provided to you by an intermediary marketing company?
  • You will be likely be barred from enrolling in the Medicare program for a period of 10 years. In light of the cases we have handled since the issuance of the November 4th Final Rule, it appears to be CMS’s policy to seek to impose a 10-year enrollment bar in revocation cases based on a violation of 42 C.F.R. § 424.535(a)(10).
  • You will likely be placed on Medicare’s “Preclusion List.” Individuals and entities that have been revoked from Medicare, are under an active reenrollment bar, AND CMS has determined that the underlying conduct that led to the revocation is detrimental to the best interests of the Medicare program may qualify to be placed on the Medicare Preclusion List.  The Preclusion list is made available to Medicare Advantage and Part D plans.   If placed on the Preclusion List, an individual or entity will not be permitted to enroll in the Medicare Part C or Part D programs.
  • A Medicare revocation action may result in the revocation of your enrollment as a provider in your state’s Medicaid program. Using Texas as an example, Rule § 371.1703(a) of the Texas Administrative Code provides that:

“(a) The OIG may terminate the enrollment or cancel the contract of a person by debarment, suspension, revocation, or other deactivation of participation, as appropriate. The OIG may terminate or cancel a person’s enrollment or contract if it determines that the person committed an act for which a person is subject to administrative actions or sanctions. . . .

(b)(7) a provider that is terminated or revoked for cause, excluded, or debarred under Title XVIII of the Social Security Act or under the Medicaid program or CHIP program of any other state;[7]

  • A Medicare revocation action will result in a report being sent to the National Practitioner Databank (NPDB). As the NPDB Guidebook[8] notes, “formal or official actions such as revocation of suspension of a license, certification agreement, or contract for participation in government health care programs; reprimand; censure; or probation,” is considered to be a final adverse action and must be reported by a Federal agency.
  • A report to the NPDB may result in an investigation by your State Medical Board. A revocation action based on your failure to provide records to a UPIC may generate a collateral investigation by your state licensing board since you are likely required to maintain adequate patient records.  For instance, under Rule § 165.1(a) of the Texas Administrative Code, a licensed physician is required to maintain an “adequate medical record” for each patient that is complete, contemporaneous and legible.  Your failure to maintain a copy of the records you reviewed when making a telemedicine evaluation may constitute a violation of your obligations under the Texas Medical Practice Act. As such, you may be subject to disciplinary action.
  • A Medicare revocation of your billing privileges may result in the termination of your hospital credentialing. Many hospitals require that a physician, nurse practitioner or physician assistant be enrolled in the Medicare program (or at the very least, be eligible to enroll in the Medicare program), in order to be credentialed and granted privileges.  If you have been barred from enrollment in Medicare, you may not be eligible to obtain privileges at a hospital.
  • Termination from commercial payor agreements. Unfortunately, Medicare revocation actions are often used by commercial payors as a basis for terminating a provider from their plan.
  • Loss of employment. The collateral consequences of a Medicare revocation action can greatly limit your ability to work for a practice or entity that treats Medicare and Medicaid patients.   As a result, you may be terminated from employment.

IV.  Responding to a UPIC Request for Records:

We cannot overemphasize the seriousness of a UPIC request for records, especially when those records are related to your telemedicine evaluation of a patient’s DME needs.  Remember – UPICs are tasked with identifying suspected cases of fraud and abuse being committed against the Medicare and Medicaid programs.   Should you fail to provide records requested by a UPIC, the proposed revocation of your Medicare billing privileges may be the least of your problems.  Therefore, it is essential that you engage qualified health law counsel to represent you and guide you through this administrative process.  Liles Parker attorneys have extensive knowledge of the Medicare revocation process and have successfully represented multiple physicians and nurse practitioners in the appeal of a proposed revocation action, including those involving failure to respond to a records request.  For a free consultation, give us a call.  We can be reached at: (202) 298-8750.

Robert W. Liles defends health care providers in Medicare auditsRobert W. Liles serves as Managing Partner at the health law firm, Liles Parker, Attorneys and Counselors at Law.  Liles Parker attorneys represent physicians, NPs and PAs in connection with Medicare revocation actions, administrative audits (UPIC audits / private payor audits), civil False Claims Act cases, and criminal violations of the Federal Anti-Kickback Statute and EKRA.  Are you currently being audited or under investigation?  We can help.  For a free initial consultation regarding your situation, call Robert at: 1 (800) 475-1906.

[1]  Often the companies identify themselves as “locum tenens” agencies, or “telemedicine providers.” Most have a contract the physician signs that (1) doesn’t permit the physician to retain any patient records, and (2) requires the physician to agree not to file any claims or bill the patient.

[2] A variety of telemedicine compliance issues arise at this stage of the agreement.  Many times, the physician does not directly speak with the patient.  The physician’s agreement with the intermediary may say that the physician is supposed to conduct their telemedicine services “in compliance with their state licensing law” but most physicians have no idea what their state law requires.

[3] Licensed providers are not usually privy to the terms of any business relationship between a telemedicine marketing company and an associated DME supplier, compound pharmacy or testing laboratory.

[4] For an overview of the various reasons that a provider’s Medicare enrollment and billing privileges may be revoked, please see our article titled 42 CFR Sec. 424.535(a) Medicare Revocation Actions — Your Medicare Billing Privileges Can be Revoked For a Host of New Reasons. Are You Facing a Medicare Revocation Action? If so, You Must Act Fast to Preserve Your Appeal Rights.(March 9, 2020).

[5] See Medicare, Medicaid, and Children’s Health Insurance Programs; Program Integrity Enhancements to the Provider Enrollment Process, 84 Fed. Reg. 47794 (Sep. 10, 2019).

[6] See 42 C.F.R. § 424.535(a)(10).

[7] Title 1, Part 15, Rule § 371.1703(a) of the Texas Administrative Code, “Termination of Enrollment or Cancellation of Contract.”

[8] NPDB Guidebook (October 2018), (Page E-81).

Responding to a Medicare Revocation Action Effective Prior to November 4, 2019

Download PDF

A Medicare revocation action can be devastating on your medical practice.

(UPDATE:  March 9, 2020):  A Medicare revocation action can destroy the financial viability of your practice.  Moreover, effective November 4, 2019, the reasons for which a health care provider or supplier may have its Medicare billing privileges revoked have greatly expanded. Our article titled “42 CFR Sec. 424.535(a) Medicare Revocation Actions — Your Medicare Billing Privileges Can be Revoked For a Host of New Reasons. Are You Facing a Medicare Revocation Action? If so, You Must Act Fast to Preserve Your Appeal Rights,” discusses these revocation reasons in much more detail).  After reviewing the materials below, we strongly recommend that you also review the updated article linked above. 

The information in this article only applies to a Medicare revocation action with an effective of November 3, 2019 or earlier.  During 2015, more than 1.2 million non-institutional health care providers participated in the Medicare program. [1]  Over the last year, a number of these providers have unexpectedly found themselves in a difficult situation where their Medicare number has been either “deactivated” or “revoked.”  While Medicare deactivation actions remain somewhat rare, over the past year, the number of Medicare revocation actions taken by Medicare Administrative Contractors (MACs) appears to have greatly increased. Both of these actions will effectively suspend a provider’s ability to bill for services rendered to Medicare beneficiaries. In order to receive reimbursement for services rendered to Medicare beneficiaries, a provider must properly enroll in the Medicare program and remain compliant with all of its conditions of enrollment and participation requirements. [2] The purpose of this article is discuss the differences between these two types of adverse actions and possible remedial steps that you can take if your Medicare number is deactivated or revoked.

I.  What is a Medicare Revocation Action?

 When a health care provider’s Medicare number is revoked, its billing privileges are terminated.  Notably, the associated provider agreement is also automatically terminated. There are a wide variety of bases upon which a revocation action can be initiated.  The two primary reasons for revocation we have addressed in recent months have included licensure-based actions and those resulting from a provider’s failure to report an adverse action or change in location.

  • Noncompliance

Unfortunately, if a physician, falls out of compliance with applicable enrollment requirements, his or her Medicare billing privileges may be revoked. Typically, revocation actions associated with this reason result from a determination by a Medicare contractor that a physician or his / her practice no longer meets all of the necessary registration requirements.  When this occurs, the contractor notifies the CMS Provider Enrollment & Oversight Group with the pertinent provider information and its recommendation that a revocation action be authorized.

For instance, Medicare requires that physician services be furnished by a doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the state in which he or she practices. The Medicare Program Integrity Manual (MPIM) further elaborates on this basis for revocation in cases where a physician is not appropriately licensed: “…situations in which § 424.535(a)(1) may be used a revocation reason include [where]…[t]he provider or supplier is not appropriately licensed.” MPIM Ch. 15 § 15.27.2(A)(1)(c).

This basis for revocation is especially pertinent in a large state like Texas, where the Texas Medical Board remains active with respect to disciplinary actions.  At its June 10, 2016 meeting, the Texas Medical Board disciplined 78 licensed physicians and issued one cease and desist order. A significant number of these disciplinary actions resulted in licensure revocation or suspension.  Each of these adverse disciplinary actions would likely result in the revocation of a physician’s billing privileges.

  • Failure to Report.

Should a provider fail to comply with its reporting requirements under 42 C.F.R. 424.516(d)(1)(ii) and (iii), which include “any adverse legal action” and / or “a change in location,” CMS may revoke the provider’s billing privileges.  Additional reasons for revocation we have seen also include:

  • Provider or Supplier Conduct.

 Under this regulatory provision, if a provider (or supplier), or an owner, managing employee, authorized or designated official, medical director, supervising physician or other health care personnel of the provider (or supplier) is excluded from the Medicare, Medicare or other federal health care program, the provider’s Medicare number can be revoked and its billing privileges terminated.  This basis for revocation is especially harsh – it can be imposed based on the fact that a provider has failed to adequately screen out employees, staff and contractors that have been excluded from participation in one or more federal health benefit programs.  Debarment or suspension from federal procurement and nonprocurement programs can also result in revocation.

  • Felonies.

If a provider (or supplier) or any owner or managing partner of the provider (or supplier) has been convicted of a federal or state felony within the past 10 years and CMS determines that the offense is detrimental to the best interest of the Medicare program, the agency may revoke the provider’s Medicare number.

  • False or Misleading Information.

If a provider or supplier has certified as “true” false or misleading information on an enrollment application, its Medicare number may be revoked.  Importantly, such an action may also constitute a violation of criminal law due to the submission of a “false statement” to the government.

  • On-Site Review.

If a program integrity contractor (such as a Unified Program Integrity Contractor (UPIC)) visits your office and makes a determination that your practice or agency is no longer operational or fails to meet another Medicare enrollment requirement, the UPIC will recommend to CMS that your Medicare billing privileges be revoked.  This often occurs when a provider moves offices and either fails to notify Medicare of the move in a timely fashion OR a Medicare contractor claims that it never received notice of the change in location.  Importantly, it isn’t merely enough for a provider to be able to show that notice of the change in location was actually sent – you need to be able to prove that the Medicare contractor RECEIVED the notice.

  • Misuse of Billing Number

If a provider knowingly sells its billing number or allows another individual or entity to use its billing number, CMS can revoke the provider’s billing privileges.  Exceptions are permitted for a valid reassignment of benefits or a change of ownership.

  • Abuse of Billing Privileges.

Should CMS determine that a provider has engaged in abusive billing practices, it can revoke the provider’s billing privileges.  Examples cited in the regulation include:

Billing for services provided to a Medicare beneficiary that is deceased.

Billing for services when either the physician or the beneficiary is not in the state or the country when the service was supposedly rendered.

Billing for services that require certain testing equipment when that equipment was not available at the location where the services were allegedly rendered.

CMS may also revoke a provider’s billing privileges if it determines there is a pattern or practice of submitting claims that fail to meet Medicare’s requirements.  When considering this basis for revocation, CMS considers:

The percentage of claims that were denied.

The reasons for claims denials.

Whether or not the provider has a history of previous final adverse actions.

The length of time over which a pattern or practice or improper billing has taken place.

How long the provider has been enrolled in the Medicare program.

Any other information that CMS feels is relevant in its determination of whether a pattern or practice of improper billing has occurred.

II.  What is the Effect of the Revocation of a Provider’s Billing Privileges?

The revocation of a provider’s billing privileges can destroy the provider’s practice.  A provider will be barred from participating in the Medicare program for a minimum of one to three years, depending on the basis for revocation and the facts in a particular case.  Once this period has expired, a provider will be required to submit a new enrollment application to CMS for its review and consideration.

III.  Responding to Medicare Revocation Action:

What actions should you take if your Medicare billing privileges have been revoked?  While a provider may choose to represent themselves in the appeal of a revocation action, we recommend that you engage experienced legal counsel to assist you with this process. A well written letter telling your side of the story is unlikely to persuade a reviewer at reconsideration that your billing privileges should be restored.  Successful defenses of revocation actions typically require a careful analysis of both the facts and the law.  Liles Parker attorneys have represented a wide variety of health care providers and suppliers in Medicare revocation actions.  Please give me a call for a free consultation on your case.

Medicare revocationRobert W. Liles, M.B.A., M.S., J.D., serves as Managing Partner at Liles Parker, Attorneys & Counselors at Law. Liles Parker is a boutique health law firm, with offices in Washington DC, Houston TX, and Baton Rouge LA. Robert represents physicians and other health care providers around the country in connection with Medicare revocation actions. Our firm also represents health care providers in connection with federal and state regulatory reviews and investigations. For a free consultation, call Robert at: 1 (800) 475-1906.

[1] https://www.cms.gov/fastfacts/

[2]     42 C.F.R. § 424.505; MPIM Ch. 15 § 15.1.

2014 HCFAC Report — $27.8 Billion Recovered for Medicare

Download PDF

Fraud(March 23, 2015):  Last week, the Department of Justice (DOJ) and Department of Health and Human Services (HHS) announced that they had recovered more than $27.8 billion to the Medicare Trust Fund due to the efforts of the Health Care Fraud and Abuse Control Program (HCFAC). As set out in the 2014 HCFAC Report, in Fiscal Year 2014, the government’s health care fraud prevention and enforcement efforts recovered $3.3 billion in taxpayer dollars from individuals and companies that attempted to defraud federal health programs. In particular, the agencies recovered $7.70 for every dollar spent to fight health care related fraud and abuse. This figure represented the third highest dollar amount on record and represents about $2 more than the average return on investment in the HCFAC program since its creation in 1997.

As HHS Secretary Sylvia M. Burwell noted:

“[e]liminating fraud, waste and abuse is a top priority” for HHS. “These impressive recoveries for the American taxpayer demonstrate our continued commitment to this goal and highlight our efforts to prosecute the most egregious instances of health care fraud and prevent future fraud and abuse. New enrollment screening techniques and computer analytics are preventing fraud before money ever goes out the door. And together with the continued support of Congress and our partners at the Department of Justice, we’ve cracked down on tens of thousands of health care providers suspected of Medicare fraud – all of which are helping to extend the life of the Medicare Trust Fund.”  

DOJ Attorney General Eric Holder expanded upon Secretary Burwell’s comments:

“As the innovative and collaborative work of the [HCFAC] proceeds, more taxpayer money is being recovered, more criminals are facing justice, and more fraud is being punished, prevented, and deterred… [t]he extraordinary return on investment we’ve obtained speaks to the skill, the tenacity, and the inspiring success of the hardworking men and women fighting on behalf of the American people. And with these outstanding results, we are sending the unmistakable message that we will not waver in our mission to pursue fraud, to protect vulnerable communities, and to preserve the public trust.”

The DOJ and HHS have been operating under a two-pronged strategy to fight waste, fraud and abuse in the federal health care programs. Under new powers granted by the Affordable Care Act (ACA), these agencies have moved away from the traditional “pay and chase” methods for targeting fraudsters. Instead, they are not working towards preventing health care fraud and abuse in the first place. Furthermore, the Health Care Fraud Prevention and Enforcement Action Team (HEAT), a joint operation run by the HHS Office of the Inspector General (OIG) and DOJ, is changing how the federal government combats certain types of health care fraud. HEAT units are investigating potential fraud cases using real-time data analysis instead of a prolonged subpoena and account analyses. This new approach has resulted in significantly shorter periods of time between fraud identification, arrest, and prosecution.

Government agencies have also utilized the federal False Claims Act (FCA) as another vital tool to combat waste, fraud and abuse. According to the 2014 HCFAC Report, since January 2009, DOJ has recovered more than $15.2 billion in settlements and judgments from civil cases involving health care fraud and false claims against federal health care programs like Medicare and Medicaid.  As detailed on the 2014 HCFAC Report, in the past year, the DOJ obtained $2.3 billion in cases involving health care fraud.

Moreover, the Centers for Medicare & Medicaid Services (CMS) has adopted its own set of preventive measures to combat waste, fraud and abuse in the health care programs. From the outset, CMS has implemented vital safeguards to prevent illegitimate providers from enrolling in and billing the Medicare program. The ACA also requires CMS to revalidate all existing 1.5 million Medicare suppliers and providers under new and updated screening requirements. This has led to the deactivation of at least 470,000 enrollments and revocation of nearly 28,000 enrollments to prevent certain providers from re-enrolling and billing the Medicare program. CMS also issued a regulation that requires prescribers of Medicare Part D drugs to enroll in Medicare and undergo screening. Another ongoing preventative measure has been CMS’ ongoing moratoria on the enrollment of new home health or ambulance service providers in six health care fraud “hot spots”: Miami, Chicago, Dallas, Houston, Detroit and Philadelphia (which includes some counties in New Jersey). CMS believes that this extension will allow it to continue its actions to suspend payments or remove providers from the program before allowing new providers into potentially over-supplied markets.

The HCFAC annual report is available at www.oig.hhs.gov/publications/hcfac.asp. We applaud the government’s efforts to combat waste, fraud and abuse in the federal health care programs. As these latest updates demonstrate, Medicare and Medicaid fraud prevention efforts will continue to expand. With this, providers should also be aware that there will likely be an increase in the number of FCA cases that are filed.   FCA cases have become increasingly important as the Justice Department looks to stop the rising tide of fraud and abuse in the nation’s healthcare system. Thus, health care providers and suppliers should ensure that their compliance programs are effective to identifying and deterring potential violations of the FCA and other laws.

Saltaformaggio, RobertRobert Saltaformaggio, Esq., serves as an Associate at Liles Parker, Attorneys & Counselors at Law.  Liles Parker attorneys represent health care providers around the country in connection with Medicaid audits by federal and state agencies and CMS-engaged specialty contractors.  The firm also represents providers in connection with HIPAA Omnibus Rule risk assessments, privacy breach matters, State Licensure Board inquiries and regulatory compliance reviews.  For a free consultation, call Robert at:  1 (800) 475-1906

Health Care Law Representation

January 1, 2021 by  
Filed under

Download PDF

Health Care Law Representation

Liles Parker attorneys have decades of experience practicing health care law.  Several of our attorneys served as Federal prosecutors and held significant positions at the U.S. Department of Justice.  Our health care transactional and regulatory attorneys have the knowledge and counseling skills necessary to efficiently resolve your health care business issues at the lowest possible level, before they escalate into a more significant problem.  Areas of practice include, but are not limited to:

Claims Audits by UPIC, MAC, CERT and SMRC Contractors:

Private Payor Claims Audits:

Administrative Adverse Actions Against Health Care Providers and Suppliers:

DOJ Investigations and Prosecutions:

OIG Audits, Investigations and Exclusion Actions:

HIPAA Privacy and OSHA Compliance, Audits and Investigations:

State Licensure Board Disciplinary Actions:

NATIONWIDE REPRESENTATION   Call: 1 (800) 475-1906.

Liles Parker attorneys are both seasoned health care lawyers AND have undergone special training and education so that they could become Certified Professional Coders (CPCs), Certified Medical Reimbursement Specialists (CMRSs) and / or Certified Medical Compliance Officers (CMCOs). We handle a full range of health law matters and cases.  Questions?  For a free consultation, give us a call.  We can be reached at:  1 (800) 475-1906.

Liles Parker Attorneys Practice Health Care Law Nationwide. 1 (800) 475-1906

Small Business Administration Releases Express Bridge Loan Pilot Program for COVID-19

Download PDF

Express Bridge Loan Pilot Program COVID-19(March 26, 2020): The Small Business Administration (“SBA”) announced an Express Bridge Loan Pilot Program on March 25, 2020.[1]   The Express Bridge Loans are available to businesses, including health care providers, to provide economic relief for businesses impacted by the Coronavirus Disease (COVID-19) while they await long-term disaster financing.[2]

 

I.   Background:

The Express Bridge Loan Pilot Program was released by the SBA in October 2017 and was created to supplement the SBA’s ability to grant direct disaster loans.[3]  The program provides “expedited guaranteed bridge loan financing for disaster-related purposes” to any small business that is located in a Presidentially-declared disaster area[4] while the business awaits long-term financing, regardless of whether the long-term financing is sought through the SBA disaster loan program.  The Express Bridge Loan Program includes a “streamlined underwriting process” and is designed to “minimize the burden” of applying for a small business loan.[5]

II.   COVID-19 Expansion of the Express Bridge Loan Program:

The SBA expanded its Express Bridge Loan Program, effective March 25, 2020,[6] to include all small businesses impacted by COVID-19 Emergency Declaration.[7] This proclamation includes all states, U.S. Territories, and the District of Columbia. Express Bridge Loans can be approved for health care providers through March 13, 2021.

Express Bridge Loans may be granted at a maximum amount of $25,000 for a loan term of 7 years.  The maximum allowable interest rate is 6.5% over the Prime rate, regardless of the maturity of the loan.[8] A lender may charge an applicable fee of 2% of the loan amount (or $250), whichever is greater.[9] Lenders are not required to take collateral for Express Bridge Loans. The minimum accepted credit score is a FICO Small Business Scoring Service Score of 130.

a. Who is Eligible for an Express Bridge Loan?

Any small business located in any U.S. state, territory, or the District of Columbia that was operational on March 13, 2020.

b. How Does a Health Care Provider Qualify for an Express Bridge Loan?

A health care provider interested in applying for an Express Bridge Loan must demonstrate that it does not have credit available elsewhere.[10]  This can be achieved by having a lender[11] certify on a Lender’s Application for Loan Guaranty Form (SBA Form 1920) that the provider does not have the ability to obtain some or all of the requested loan amount from a non-Federal source, including from the lender completing the form, without SBA assistance.  The lender must also document that the provider / applicant had an operating business located in a disaster area on March 13, 2020, which was adversely impacted by COVID-19.

The provider / applicant must also complete the SBA 7(a) Borrower Information Form (SBA Form 1919). This form should be submitted to the provider’s lender. The form requires information about each of the applicant’s principals, which includes:

  • Sole proprietors;
  • For a general partnership: all general partners and all limited partners owning 20% or more of the equity of the business; or any partner that is involved in the management of the business;
  • For a corporation: all owners of 20% or more of the corporation, and each officer and director;
  • For limited liability companies: all members owning 20% or more of the company, each officer, director, and managing member;
  • Any person hired by the business to management day-to-day operations (“key employees”); and
  • Any Trustor (if the business is owned by a trust).

A separate SBA Form 1919 should be completed and signed by each of the above principals.[12] Finally, the lender must a signed IRS Form 4506-T to obtain an IRS transcript before it disburses the loan.[13]

C. How Soon Will a Provider Receive an Express Bridge Loan Payment?

The first disbursement of an Express Bridge Loan “should occur” within 45 days of the lender’s receipt of an SBA loan number. Disbursement must occur within 90 days of receipt of an SBA loan number or the loan will be cancelled.[14]  The SBA “endeavors” to provide loan numbers within one business day of receipt of the application (if filed through the SBA’s electronic transmission system, “E-Tran”).

III.   Conclusion:

The Federal Government is working with the SBA to make emergency funds available as quickly as possible to providers affected by COVID-19. Liles Parker attorneys are closely monitoring the available programs and are available to assist health care providers with the loan process and to answer any other concerns in response to this National Emergency.

Ashley Morgan is a Senior Associate at the health law firm, Liles Parker, PLLC.  Ms. Morgan represents health care providers and suppliers around the country in a wide variety of regulatory matters.  These include but are not limited to Medicare revocation, suspension and deactivation actions, prepayment reviews, postpayment claims audits, and State Board licensure matters.  Ms. Morgan is also assisting health care providers and suppliers adversely affected by COVID-19 with the completion and submission of SBA business loans.  For a free consultation regarding your needs, please give Ms. Morgan a call.  She can be reached at (202) 298-8750 or toll-free at 1 (800) 475-1906.

[1] Express Bridge Loan Pilot Program Guide, Small Business Administration, https://www.sba.gov/document/support–express-bridge-loan-pilot-program-guide (last accessed Mar. 26, 2020).

[2] COVID-19 SBA Loan Support May be Available for Qualified Health Care Providers, Liles Parker PLLC (Mar. 25, 2020) https://www.lilesparker.com/2020/03/25/covid-19-sba-loan/ (last accessed Mar. 26, 2020).

[3] 82 Fed. Reg. 47958, Express Bridge Loan Pilot Program; Modification of Lending Criteria (Oct. 16, 2017) (codified at 13 CFR Part 120).

[4] Current Declared Disasters, Small Business Administration, https://disasterloan.sba.gov/ela/Declarations (last accessed Mar. 26, 2020).

[5] Express Bridge Loan Pilot Program: Program Guide v.2, Small Business Administration, Mar. 25, 2020, p. 3, available at: https://www.sba.gov/document/support–express-bridge-loan-pilot-program-guide (last accessed Mar. 26, 2020).

[6] According to the SBA the expansion of the Express Bridge Loan Program will be published in the Federal Register. Express Bridge Loan Pilot Program: Program Guide v.2, Small Business Administration, Mar. 25, 2020, p. 3, available at: https://www.sba.gov/document/support–express-bridge-loan-pilot-program-guide (last accessed Mar. 26, 2020).

[7] This Emergency Declaration was issued by President Trump on March 13, 2020. Donald Trump, Proclamation on Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak, The White House, Mar. 13, 2020, https://www.whitehouse.gov/presidential-actions/proclamation-declaring-national-emergency-concerning-novel-coronavirus-disease-covid-19-outbreak/ (last accessed Mar. 26, 2020).

[8] Express Bridge Loan Pilot Program: Program Guide v.2, Small Business Administration, Mar. 25, 2020, p. 7-8, available at: https://www.sba.gov/document/support–express-bridge-loan-pilot-program-guide (last accessed Mar. 26, 2020).

[9] An SBA Form 159 must be completed and signed by the applicant and lender if the lender charges an application fee. Express Bridge Loan Pilot Program: Program Guide v.2, Small Business Administration, Mar. 25, 2020, p. 11, available at: https://www.sba.gov/document/support–express-bridge-loan-pilot-program-guide (last accessed Mar. 26, 2020).

[10] 42 C.F.R. § 120.101.

[11] The lender must have an existing banking relationship with the provider/applicant as of the date of the applicable disaster. Program Guide v.2, Small Business Administration, Mar. 25, 2020, p. 9, available at: https://www.sba.gov/document/support–express-bridge-loan-pilot-program-guide (last accessed Mar. 26, 2020).

[12] SBA 7(a) Borrower Information Form, Small Business Administration (SBA Form 1919) (OMB Control No. 3245-0348) (Exp. Date July 31, 2020).

[13] Express Bridge Loan Pilot Program: Program Guide v.2, Small Business Administration, Mar. 25, 2020, p. 11-12, available at: https://www.sba.gov/document/support–express-bridge-loan-pilot-program-guide (last accessed Mar. 26, 2020).

[14] Express Bridge Loan Pilot Program: Program Guide v.2, Small Business Administration, Mar. 25, 2020, p. 12, available at: https://www.sba.gov/document/support–express-bridge-loan-pilot-program-guide (last accessed Mar. 26, 2020).

COVID-19 SBA Loan Support May be Available for Qualified Health Care Providers

Download PDF

A COVID-19 SBA Loan May be Available for Your Health Care Practice.(March 25, 2020):  The Small Business Administration (SBA) offers loans to small businesses through community lenders.  The SBA acts as guarantor for these loans. In addition to the traditional lending, the SBA is also authorized to offer disaster assistance to businesses, renters, and homeowners who are located in regions with “declared disasters.”[1]  Small businesses impacted by Coronavirus (COVID-19) are eligible to apply for Disaster Loan Assistance from the SBA.[2]  As of January 31, 2020, individual states and the District of Columbia have been declared disaster areas.[3] These Economic Injury Disaster Loans (Disaster Loans or COVID-19 SBA loans) may be used by businesses to pay “fixed debts, payroll, accounts payable and other bills that can’t be paid because of the disaster’s impact.”[4]  The SBA may offer up to $2 million in Disaster Loan assistance with repayment options up to 30 years at an interest rate of no more than 3.75% for small businesses without credit available elsewhere.[5] If a business is a major source of employment, then SBA may waive the $2 million statutory limit.[6]

How can you apply for COVID-19 SBA loan?  The SBA utilizes a three-step process to administer disaster loans (such as those related to COVID-19 losses).  First, an applicant must submit an application for a Disaster Loan.  The SBA encourages online applications, but paper forms are available.[7] Second, the SBA will review the applicant’s credit and eligibility.  Third, the SBA will prepare and send loan closing documents and make an initial disbursement.  The initial disbursement for economic injuries is $25,000.[8]

Small businesses must complete several forms and provide the following information to apply for a Disaster Loan / COVID-19 SBA Loan [9]:

  • A Disaster Loan Application (SBA Form 5) must be filed.

  • A Tax Information Authorization (IRS Form 4506T) must be completed and signed by each applicant, each person owning 20 percent or more of the business, each general partner or managing member, and, any owner who has greater than 50 percent ownership in an affiliate business.

    • Affiliates include, but are not limited to, business parents, subsidiaries, and / or other businesses with common ownership or management.
  • The applicant must provide complete copies (including all schedules) of the business’s most recent Federal income tax return. An explanation may be submitted if a copy of the income tax return is not available.

  • A Personal Financial Statement (SBA Form 413) must be completed, signed, and dated by: (1) the applicant, (2) each principal owning 20% or more of the applicant business, and (3) each general partner or managing member.

Each form requires detailed information and it is critical to accurately complete the forms to avoid delays in processing or requests for additional information. Liles Parker attorneys are available to assist health care providers with the SBA Disaster Loan application process and to answer any other concerns in response to this National Emergency and your possible eligibility for a COVID-19 SBA loan.  For a free consultation, call Ashley Morgan at (202) 298-8750 or toll-free at 1 (800) 475-1906.

[An updated article dated March 26, 2020, titled “Small Business Administration Releases Express Bridge Loan Pilot Program for COVID-19” is available at this link.]

Ashley Morgan is a Senior Associate at the health law firm, Liles Parker, PLLC.  Ms. Morgan represents health care providers and suppliers around the country in a wide variety of regulatory matters.  These include but are not limited to Medicare revocation, suspension and deactivation actions, prepayment reviews, postpayment claims audits, and State Board licensure matters.  Ms. Morgan is also assisting health care providers and suppliers adversely affected by COVID-19 with the completion and submission of SBA business loans.  For a free consultation regarding your needs, please give Ms. Morgan a call.  She can be reached at (202) 298-8750 or toll-free at 1 (800) 475-1906.

[1] Disaster Assistance, Small Business Administration, https://www.sba.gov/funding-programs/disaster-assistance (last accessed Mar. 25, 2020).

[2] Economic Injury Disaster Loans, Small Business Administration, https://disasterloan.sba.gov/ela/Information/EIDLLoans (last accessed Mar. 25, 2020).

[3] A list of Declared Disasters is available on the SBA website. Current Declared Disasters, Small Business Administration, https://disasterloan.sba.gov/ela/Declarations (last accessed Mar. 25, 2020).

[4] SBA to Provide Disaster Assistance Loans for Small Businesses Impacted by Coronavirus (COVID-19), Release No. 20-24, Small Business Administration, Mar. 12, 2020, https://www.sba.gov/about-sba/sba-newsroom/press-releases-media-advisories/sba-provide-disaster-assistance-loans-small-businesses-impacted-coronavirus-covid-19 (last accessed Mar. 25, 2020).

[5] The interest rate for non-profits is 2.75%. Id.

[6] U.S. Small Business Administration Fact Sheet – Economic Injury Disaster Loans – Texas Declaration #16381: Incident: Coronavirus (COVID-19), Small Business Administration, available at: https://disasterloan.sba.gov/ela/Declarations/DeclarationDetails?declNumber=6064043&direct=false (last accessed Mar. 25, 2020).

[7] The online application portal for disaster loans, where you can also access paper applications is available here.

[8] Three Step Process: Disaster Loans, Small Business Administration, https://www.sba.gov/sites/default/files/files/Three_Step_Process_SBA_Disaster_Loans.pdf (last accessed Mar. 25, 2020).

[9] The SBA Schedule of Liabilities form (SBA Form 2202) may be used to identify all fixed debts to assist applicants in completing these forms.

 

Are you Ready for the Next Round of CMS Revalidation?

Download PDF

CMS revalidation(March 17, 2017): The Centers for Medicare and Medicaid Services (CMS) recently announced that it will be initiating its next round of CMS revalidation requests to all Medicare enrolled providers and suppliers.  Current law and regulations require providers and suppliers to revalidate their enrollment with Medicare every five years (every three years for DME suppliers). There are a few changes being made to try and give providers a bit more flexibility this time around.

 

 I.  Highlights of the CMS Revalidation Initiative Beginning This Year:

  • CMS will maintain a master list of providers/suppliers due for revalidation along with the due date for their applications here: https://data.cms.gov/revalidation. CMS has advised that all providers/suppliers should check this list to see when their application is due. If a due date is more than six months away, the list will show “TBD” for a provider/supplier due date. DO NOT SUBMIT A REVALIDATION APPLICATION IS NO DUE DATE APPEARS. IT WILL BE RETURNED.
  • The website will also provide a list of all reassignments for those suppliers that maintain reassignments.
  • Providers and suppliers don’t have to wait for a letter from their Medicare Administrative Contractor (“MAC”) to submit a revalidation application. If you are within six month of your due date shown on the above website, you are encouraged to submit your application.
  • MACs will still send an email or letter to providers/suppliers 2-3 months prior to their due date asking them to revalidate. Emails will include the title “URGENT: Medicare Provider Enrollment Revalidation Request.” If emails are returned as undeliverable, a paper letter will be sent. All letters will be sent to at least two of a providers/suppliers reported addresses (e.g. a correspondence and special payments or primary practice location address.
  • Revalidation notices sent to individual practitioners who have reassigned their billing rights to a group or groups will include a list of all reassignments on file with CMS. Special procedures will be available for groups with more than 200 members.
  • An upcoming revalidation does not relieve providers/suppliers from submitting updates to their enrollment record in the timeframes required by relevant regulations. Submit all changes of information timely, even if a revalidation is due within the next six months.

II.  Tipe for Ensuring Your CMS Revalidation Efforts Have Been Completed:

In addition to outlining the process for the next round of revalidation, CMS has provided tips for ensuring your revalidation is complete.

  • Providers and suppliers are required to revalidate their entire Medicare enrollment record, including all practice locations where they see patients and all groups to which they reassign benefits.
  • All of a provider’s or supplier’s NPIs and PTANs must be revalidated when revalidation is requested.
  • Either PECOS or the paper CMS-855 applications may be used for revalidation.
  • If a provider or supplier is deactivated for failing to submit a revalidation application on time or failing to respond to a request for additional information on a pending application, they may reactivate their enrollment by submitting a new, full application. The provider/supplier, once the application is processed and approved, will maintain their original PTAN, but the reactivation date will be whatever date the new, full application was submitted. Retroactive billing privileges back to the date of deactivation will not be granted and the provider/supplier will have gap period where they may not receive payment for services provided to Medicare beneficiaries.
  • CMS has reminded certain providers and suppliers that a fee is due with their revalidation application. All “institutional providers” that submit an application via PECOS or a paper Medicare enrollment application using the CMS-855A, CMS-855B (except physician and non-physician practitioner organizations), or CMS-855S forms are required to pay the application fee. For Calendar Year 2017, the fee is $560. It can be paid via this website: https://pecos.cms.hhs.gov/pecos/feePaymentWelcome.do#headingLv1 Be sure to print proof of payment with your revalidation application to avoid delays in processing.

III.  Other Important Considerations:

CMS also noted that all providers and suppliers that have not billed Medicare for 12 consecutive months will have their billing privileges deactivated. To reactivate their provider number, a complete, new application must be submitted. Once approved, the provider/suppliers will retain its original PTAN.  The effective date of reactivation will not be retroactive to the date of deactivation.

We encourage all providers and suppliers to check CMS’ list of revalidations due in the upcoming six months. The list is updated every sixty days. If you choose to use PECOS to complete your revalidation, be sure to print a copy of your submission BEFORE you click the submit button. You need to retain a copy of what you submit indefinitely in order to substantiate what you input via PECOS. We have seen far too many providers and suppliers think they properly completed a revalidation application via PECOS only to be revoked later on because some data point was missing from a submission or was submitted under the incorrect enrollment file or field. Also:

  • If you are a physician who is the sole shareholder of your practice, you do NOT need to complete a CMS-855B in most instances. However, it is very important to properly identify your practice locations under both your individual and your entity’s enrollment in PECOS when you revalidate those enrollments. Don’t make the mistake of thinking that listing practice locations under just your individual enrollment will make them automatically appear under your entity (or vice versa).
  • Physicians and non-physician practitioners that reassign payments to groups must identify all groups to which they reassign on their revalidation. Failure to list a group may result in a reassignment being deactivated. You do not need to submit new CMS-855Rs with your revalidation.
  • If you check the list of revalidations that are due and you can’t locate your record after searching by name or NPI…CALL YOUR MAC. The list contains all active Medicare program providers and suppliers, including DME suppliers. If you do not appear on the list, you need to find out why.

CMS has published an article discussing the revalidation process in more detail here: https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE1605.pdf  In addition, you may visit this CMS website for additional information: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Revalidations.html

IV.  Recommendations:

Liles Parker PLLC attorneys have extensive experience helping providers and suppliers navigate through the Medicare enrollment and revalidation process. Please contact us if you have questions or need assistance.

CMS revalidationJennifer Papapanagiotou, Esq is a health law attorney with the firm, Liles Parker, Attorneys & Counselors at Law.  Liles Parker has offices in Washington DC, Houston TX, McAllen TX and Baton Rouge LA.  Our attorneys represent dentists, orthodontists and other health care professionals around the country in connection with Medicare provider enrollment and revocation matters.  Need assistance?  For a free consultation, please call: 1 (800) 475-1906.