Provider Alert: Neglecting to Update Your Medicare and/or Medicaid Enrollment Status and/or Maintain Enrollment Requirements May Result in Revocation

Providers enrolled in Medicare and/or Medicaid are aware of the myriad of rules associated with coverage for services and the submission of claims, but they are sometimes surprised to learn that neglecting to update their enrollment status and maintain basic enrollment requirements can result in revocation of the provider’s billing privileges.  Unfortunately, this draconian penalty is imposed even where the violation is an inadvertent administrative oversight.

Representative matters serve as cautionary tales:

▪ The Medicare billing privileges of a large multidisciplinary medical practice were revoked because the practice failed to update its Medicare provider enrollment profile when a former shareholder departed.  The name of the former shareholder, who later became an excluded provider as a result of totally separate conduct, remained part of the practice’s Medicare enrollment profile.  Excluded providers can receive no payment from Federal healthcare programs for any items or services they furnish, order, or prescribe. For CMS, the practice’s failure to remove the excluded provider’s name was tantamount to the practice employing an excluded provider. In this case, the issue is not that the practice failed to check the OIG’s List of Excluded Individuals/Entities (LEIE) before hiring a physician, but that it neglected to remove the name of a departing shareholder who did not even become an excluded provider until after he left the practice.

▪ A pharmacy’s DME billing privileges were revoked as a result of the pharmacy failing to maintain certain required supplier standards. The inadvertent lapse of the pharmacy’s surety bond and liability insurance led to a revocation of its billing privileges for DME, and a 2-year Medicare re-enrollment bar.  This subsequently triggered revocation of the pharmacy’s Medicaid DME privileges.

Of note, these revocations were not the result of any findings or allegations that the providers knowingly submitted deficient or fraudulent claims, had failed to return an alleged overpayment, or engaged in other conduct usually associated with such a harsh penalty.  In both examples, the revocation resulted from an administrative oversight.  Even though in one case, the enrollment profile could have been easily updated, and in the other case, the pharmacy owner could have easily reactivated the lapsed insurance policy and surety bond, the system is structured to penalize non-compliant providers.  As a result, a seemingly benign, easily correctable administrative mistake can deprive a provider of its ability to submit claims for payment.  The disruption to continuity of care may be devastating to patients, and the financial impact and reputational harm caused to the provider may be existentially threatening.

How Frier Levitt Can Help

Frier Levitt has experience navigating the layers of complexity associated with appeals of this nature, and in some instances, has been able to achieve a successful rescission of the suspension or revocation. These matters require diligence, diplomacy, and in some cases, litigation.  If you have received a notice of suspension or revocation from Medicare or Medicaid, contact us to speak with an attorney.

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