Billing Practices That Could Lead to Losing Your Medicare Enrollment

 Posted on October 29, 2020 in Medical License Defense

According to the Centers for Medicare & Medicaid Services (CMS), there are currently more than 60 million Americans who are enrolled as Medicare beneficiaries. This number includes individuals enrolled in “original” Medicare as well as in Medicare Advantage plans with private insurers. In order to be able to serve this large portion of the population, a medical provider must enroll as a Medicare provider and keep that enrollment in good standing. This means the provider must meet all of the requirements set forth by CMS and avoid behaviors that could lead to a revocation of the provider’s Medicare status.

Revocation of Medicare Enrollment

Under §424.535 of the Code of Federal Regulations, there are many different reasons for which a provider could have his or her Medicare enrollment status revoked. They include noncompliance with enrollment requirements, causing harm to patients, being convicted of certain felonies, improper medication prescribing practices, and failing to comply with CMS reporting requirements, among many others.

As a provider, you could also lose your Medicare enrollment status for abusing your billing privileges. Under the law, abuse of billing privileges includes but is not limited to:

• You submit claims for services that could not have been delivered to a particular patient on the reported date of service. Such instances may include billing for services for a deceased Medicare beneficiary, billing for a date on which you or the beneficiary was not in the state or country, or billing for testing services despite not having the proper testing equipment on site.
• You have a pattern of submitting claims that do not meet CMS requirements. Some unscrupulous providers will submit claims to Medicare, expecting them to be denied so that they can bill the patient directly—often with the intention of collecting more than the contracted Medicare reimbursement rate for the services in question.
• You bill under a different name, provider ID, or business identity because your billing privileges are currently suspended or revoked. If your billing privileges have already been revoked, trying to get around the revocation by billing under a different provider number or business entity could lead to a permanent revocation of your enrollment status.
• You bill from a non-CMS compliant location. As a Medicare provider, you are only permitted to bill from practice locations that are compliant with Medicare’s enrollment requirements. CMS will consider each instance on a case-by-case basis before issuing a decision on revoking your enrollment.

Contact an Illinois Provider Enrollment Defense Lawyer

If you are currently being investigated by CMS for billing practices that could lead to the revocation of your enrollment status with Medicare, it is important to work closely with an attorney with experience in handling such cases. At The Law Offices Joseph J. Bogdan, we help providers of all types in protecting their Medicare status, and we ready to help you and your practice. Contact our Illinois Medicare enrollment defense attorney to discuss your situation today. Call 630-310-1267 for a free consultation.

Sources:

https://www.cms.gov/files/document/2018-mdcr-enroll-ab-1.pdf

https://www.law.cornell.edu/cfr/text/42/424.535