Compliance with Conditions of Participation Necessary for Reinstatement of Terminated Medicare Billing Privileges or Revoked Medicare Provider Number and Participation Agreement

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

We have recently experienced an alarming increase in the number of Medicare providers receiving notices that their Medicare billing privileges are being terminated.  These include home health agencies (HHAs), independent diagnostic testing facilities (IDTFs), ambulance and emergency transport providers, physicians, pharmacies, durable medical equipment (DME) providers, medical groups, physical therapists and therapy providers.  In most cases, this is because the health care provider has failed to update its address with the Medicare Program.  To see a prior article we wrote on this, click here.

Most often this occurs when a site visit by the Medicare administrative contractor (MAC) (previously called the carrier or fiscal intermediary) arrives at the business location on file with Medicare and finds the provider’s business location has changed.  Other times the termination is because of a minor technical violation of Medicare rules, such as being closed when a site inspector shows up, failing to have hours of operation posted, failing to have a required insurance policy in place, failing to be open at the time the inspector shows up, or other similar reasons.

If the health provider does nothing to appeal the revocation, then there is a required waiting period of at least one year before it can even reapply to the Medicare Program.  The termination may also have extremely serious consequences regarding participation in the state Medicaid Program, licensure, other contracts, clinical privileges, participation on insurance provider panels and related businesses.

We recommend immediately retaining an experienced health attorney to help you prepare and file a corrective action plan (CAP), request for reconsideration of the decision and an appeal, if necessary.  We recommend that you include proof of currently meeting every required condition of participation (COP) for your health specialty, service or item.  We include copies of written policies adopted, new forms, new procedures, insurance policies, copies of CMS forms 855 that were previously submitted, and other documents that may be required by the COP.  Please see our prior blog/article on submitting CAPs.

For access to each of the conditions of participation (COP) and conditions for coverage (CFC), click on the following link, or cut and paste it into your internet browser:

About the Author:  George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone:  (407) 331-6620.