Appeal of CMS Revocation and Enrollment Bar – Physicians Take Note.

The Centers for Medicare & Medicaid Services allows for the enrollment of various types of providers to participate in the Medicare program for reimbursement of medical services provided to beneficiaries. Typically, physicians get credentialed into the Medicare program through their employers. The employer’s staff prepares and assists with the submission of the physician’s initial enrollment application and reassignment of benefit application by the filing of a CMS-855i and CMS-855r applications with the applicable Medicare Administrative Contractor (MACs) — First Coast Service Options, Inc., Palmetto GBA, Novitas, Noridian, National Government Services, etc. The physician’s enrollment in the Medicare program requires that the physician execute a certification statement that contains certain standards that a participating provider must meet and maintain for the initial and continuous enrollment in the Medicare program, including but not limited to maintenance of documentation, access to records, and reporting requirements.

Recently, the firm has assisted physicians who have had their Medicare enrollment in the Medicare program revoked for failure to maintain and provide access to patient records. Although most physician employees do not keep copies of medical records for patients they have seen, treated or consulted on, CMS imposes a duty on all participating physicians to maintain and provide access to medical records when requested by any of MACs, or Unified Program Integrity Contractors (UPICs) such as SafeGuard Services, LLC, CovenantBridge Group, Qlarant, and/or Zone Program Integrity Contractors (ZPICs) such as SafeGuard Services, LLC, AdvanceMed, Health Integrity. Physicians will receive a request for records to their employer’s address noted in the 855 enrollment application with a notice of potential consequences for not providing access to the medical records requested. For instance, a UPIC can request copies of certain medical records in order to verify that the physician was the referring or ordering physicians for certain claims submitted by third party suppliers including durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) providers. Normally, the employer as records custodian will respond by producing copies of the records. However, there are occasions when the CMS request for record is sent to an outdated address of the employer or physician and records are not timely submited to the requesting entity. The result for failure to produce records or respond is that the physician’s participation in the Medicare program will be revoked and an enrollment bar of one to ten years will be placed on the physcian’s enrollment file. A revocation of pracitipcation and billing privileges can have a devasting affect on the physcian’s finances and livelihood.

The only recourse for physicians is timely file an administrative appeal (request for reconsideration) and if necessary and second level of appeal before an administrative law judge (ALJ). Physician’s are advised to seek the assistance of counsel experienced in these matters. Recently, Mr. Ralph Gaitan has successfully resolved three physician’s revocations each with ten year enrollment bars — one had the revocation and enrollment bar completely rescinded and the others had their enrollment bars significantly reduced from ten years to one year.

Mr. Gaitan has experience in appealing Medicare revocations and enrollment bars, appeals of placement on preclusion and/or exclusion lists, and challenging audits, suspensions and overpayment notices, demand letters and recoupment actions and sanctions. Mr. Gaitan can be reached at (786) 440-8115 or via email at [email protected] should you require additional information or assistance with this topic or any other health care related matter