Upon the annual announcement of the Medicare Physician Fee Schedule, providers are typically focused on the new payment rates and policies, but the 2020 version includes an expansion of revocation authority about which all enrolled providers must be aware. The Centers for Medicare & Medicaid Services (CMS) has always retained the discretion to deny or revoke a provider’s enrollment status and corresponding billing privileges for violations of CMS rules, but beginning on January 1, 2020, CMS will have expanded authority to take action against providers who have a history of demonstrated patient harm caused by the provider’s abusive prescribing practices. For this purpose, “patient harm” is described as “some form of physical and/or psychological injury to the patient.”
Under the new provision, CMS may revoke or deny enrollment of a provider who has been subject to prior action from a state oversight board, federal or state health care program, or other equivalent governing or regulating body or program. Notably, while CMS “generally gives great deference to state oversight boards and their judgments,” where a state medical board has decided to not ultimately take any action against a provider, CMS still reserves its right to take action against the provider’s enrollment status. Factors CMS will consider include: the nature of the patient harm, the nature of the physician’s conduct, the number and types of sanction(s) or disciplinary action(s) imposed, and the number of patients affected. To minimize the risk of a revocation of CMS enrollment on these grounds, providers must abide by prescribing regulations and best practices, and are also well-advised to seek competent health care counsel to address every potential allegation, ranging from a patient complaint to a state medical board to a medical malpractice action, as the documented, successful defense of such allegations can be used to support the appeal of a revocation decision.
Frier Levitt regularly assists providers with enrollment denials and revocations, and our recent track record includes a complex appeal in which the outcome was a retroactive rescission of the revocation of the provider’s enrollment status – a case in which the reactivation of billing privileges restored both the provider’s revenues and access to critical specialty care for thousands of Medicare beneficiaries. For more information, contact Frier Levitt to speak to an attorney.