Member Articles

While most providers understand the need to bill Medicare correctly, many often fail to recognize the potentially disastrous results of not keeping Medicare informed of your correct and up-to-date practice information. A recent case highlights the dangers of a seemingly innocent error, which resulted in a physician’s Medicare billing privileges being revoked.

In a cautionary tale, a federal court in Hawaii recently upheld CMS revoking a physician’s Medicare billing privileges due to his failure to list a correct practice address on his Medicare enrollment and revalidation applications. The physician, an anesthesiologist who had been enrolled in Medicare for over 25 years, listed a UPS store address on his enrollment application in 2010 and re-confirmed that address as part of his revalidation in 2014. The physician contended that he correctly provided his mailing address since he did not have an office where he rendered services. CMS argued that he should have reported the location where he provided services. The court upheld CMS’s decision to revoke the physician’s Medicare billing privileges for two years.

Mandated Reporting

In addition to paying careful attention to provide Medicare with the information that it requires, including in revalidations that occur at least every 5 years (every 3 years for durable medical equipment suppliers), providers also are required to notify Medicare within 30 days of:

• A change in ownership,
• An adverse legal actions (such as licensure revocation), or
• A change in practice location.

Other changes must be reported within 90 days.

Draconian Penalties

There are dozens of horror stories (and not just because of this being Halloween season) of providers being severely penalized for not complying exactly with CMS requirements. For example:

• a physician made multiple filings on a CMS 855-I form over a 5-year period to report 4 practice locations. The physician then operated only out of the 4^th location and failed to notify the MAC that he had closed the other 3 locations. After an appeal, the physician’s billing privileges were revoked and he was barred from re-enrolling for 2 years.
  
  
• Another example of the penalty far outweighing the error – a home health agency reported its new location in a letter, rather than on the correct CMS 855 form or by electronically using the PECOS system. After appeal the billing privileges were revoked even though the MAC was aware of the new location because a letter was an ineffective form of notice and not an acceptable alternative to using the correct form.

Affiliation Disclosure

Providers also should be aware of recent additional enrollment disclosure requirements. Effective November 4, 2019, a provider or supplier must disclose any current or previous “affiliation” with another provider or supplier, if that other provider or supplier:

• has uncollected Medicare, Medicaid, or CHIP debt,
• has had federal health care program payments suspended, or
• has been suspended or excluded from Medicare, Medicaid, or CHIP.

CMS defines “affiliation” broadly—including, for example, holding a five percent interest in or acting as an officer or director of an entity—meaning that the new rule requires providers and suppliers to gain and maintain an understanding of their affiliates’ positions vis à vis CMS. Providers and suppliers who fail to do so risk revocation of their Medicare privileges.

If you have any questions or wish to discuss Medicare enrollment issues in more detail, please contact your regular Verrill attorney.