Appealing CMS Revocations & Placement on Preclusion Lists

Physicians, physician groups and other medical practices please take notice and action to correct, if needed, your compliance programs and credentialing departments. As a regulated individuals or entities participating in the Medicare program, proactive compliance checks or screenings are important to receiving and responding to time sensitive documentation issued by or on behalf of the Centers for Medicare & Medicaid Services (“CMS”). In general, most of our clients are up to date with documentation requirements required for meeting the appropriate reimbursement level. However, it is not uncommon for providers to overlook the importance of vigilantly reviewing and updating their enrollment records to remove and/or adding outdated practice locations and correspondence addresses or correspondence mailing or medical record correspondence addresses contained within the applicable Medicare Enrollment Application, i.e., 855A, 855B, 855I etc.

Recently, a client of the firm had his Medicare billing privileges revoked, was sanctioned with a three year re-enrollment bar, and was placed on CMS’s preclusion list for three years. This practitioner was sent an initial CMS revocation notice to an outdated correspondence address. The revocation notice was issued by his Medicare Administrative Contractor (“MAC”) based on the provider’s enrollment record which contained an outdated correspondence address. As result, the provider did not receive the notice and could not file his appeal within the time frames (60 days) required to file. Provider learned of the revocation of his Provider Transaction Access Number (“PTAN”) and preclusion several months later, when all his Medicare Part-B payments including Medicare Advantage payments were denied.

Upon learning of the revocation the provider immediately filed an appeal to CMS’s Provider Enrollment & Oversight Group (“PEOG”) stating that he had never received the notice. Provider’s appeal and request reconsideration was denied as untimely. Provider eventually retained our firm for assistance.

Immediately, Mr. Ralph Gaitan filed an amended appeal challenging 1) the timeliness of Provider’s appeal and 2) contesting CMS’s basis for revoking Provider’s participation in the Medicare program. Mr. Gaitan argued that provider had “good cause” for filing an appeal well after the 60 days to file same (42 C.F.R. § 498.22) and that the MAC had incorrectly revoked provider’s PTAN (42 C.F.R. § 424.535). As a result of Mr. Gaitan’s efforts, Provider’s revocation as well as three-year enrollment bar and placement on the preclusion list was rescinded and all negative conditions were removed in their entirety. Within the last several months, Mr. Gaitan has successfully argued removal of revocations and enrollment bars, has also successfully reduced a ten year enrollment bar to one and another 10 year bar was completely removed, as well as successfully removing providers from from being placed on CMS’s preclusion list. Although all cases are different and results will vary depending on the facts, circumstances and applicable law of each matter, Mr. Gaitan believes his experience, persistence and dedication has enabled him to produce positive outcomes when appealing, challenging and negotiating enrollment matters before the MACS, PEOG and CMS administrative law judges.

Thus, it is recommended that health care practitioners and/or entities regardless of size have staff constantly reviewing and revalidating enrollment records to insure that any correspondence sent by CMS or its contractors or auditors (MACs, UPICs, ZPICs, etc.) are received, dated and submitted to the appropriate compliance personnel or counsel.

Mr. Rafael (Ralph) Gaitan, Esq., is experienced in these matters and can assist all different types of health care providers, from credentialing and enrollment, reimbursement analysis for national and local coverage determinations, responding to ADR requests; appealing all matters or enrollment including revocations of PTANs, 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.