Federal regulations provide 22 distinct reasons that the Centers for Medicare & Medicaid Services (CMS) may use to revoke a healthcare provider’s or supplier’s Medicare billing privileges. Any revocation can have devastating impacts on a provider, but the grounds for revocation are often misunderstood. These are some of the most common reasons CMS will assert in revoking Medicare billing privileges.
Noncompliance: CMS may revoke a provider for noncompliance with Medicare enrollment requirements. This is somewhat of a catch-all and is often used when CMS or a contractor alleges technical issues with the myriad of requirements for a provider to maintain Medicare enrollment, such as issues with a provider’s surety bond, insurance policy, or business telephone lines. This reason for revocation is unique in two ways: the contractor often has authority to revoke without asking CMS to make the decision and the provider may have the opportunity to submit a Corrective Action Plan (CAP) demonstrating that they have addressed the issue.
Felony Convictions: CMS may revoke a provider when the provider or any of its owners or managers have been convicted in the last 10 years of any felony that CMS deems detrimental to the Medicare program or beneficiaries. This most often includes financial crimes such as insurance fraud or healthcare fraud but can include many others. A guilty plea or pretrial diversion program may still constitute a conviction. Moreover, even where a provider has previously disclosed the felony conviction, CMS may still use it as a reason to revoke. Where a provider is revoked for a felony, CMS will often make the revocation retroactive and back-date it to the date of the conviction.