2023 Board Resources

(iii) Whether the provider or supplier has any history of final adverse actions and the nature of any such actions; (iv) The length of time over which the pattern has continued; (v) How long the provider or supplier has been enrolled in Medicare; and (vi) Any other relevant information regarding the provider or supplier’s specific circumstances. When a provider’s or supplier’s billing privilege is revoked, any provider agreement in effect at the time of revocation is terminated effective with the date of revocation until the end of the re- enrollment bar. The re-enrollment bar begins 30 days after notice of the revocation and lasts a minimum of one year, but not greater than three years, depending on the severity of the basis for revocation. 111 If a provider or supplier seeks to re-establish enrollment in Medicare after notification that its billing privileges are revoked, the provider or supplier must re-enroll in Medicare as a new provider or supplier and, as applicable, must be resurveyed and recertified by the state survey agency. In most circumstances, revocation becomes effective 30 days after CMS or the MAC notifies the provider or supplier. If the revocation is based on a finding of federal exclusion or debarment, felony conviction, license suspension or revocation, or determination that the practice location is not operational, the revocation is effective as of the date of that finding. 112 A provider or supplier revoked by CMS can appeal the revocation decision 113 through a process comprised of multiple levels. 114 The first level of appeal is the reconsideration appeal stage. The reconsideration appeal must be submitted within 60 days from the date of the revocation notice to the MAC (or in cases where the revocation is based on abuse of billing privileges, to CMS). 115 If a provider receives an unfavorable reconsideration decision, the provider can appeal to an Administrative Law Judge (ALJ) at the Departmental Appeals Board, Civil Remedies Division. 116 A provider must submit a written ALJ appeal request within 60 days from the reconsideration decision. Either party dissatisfied with the ALJ decision can request review of the ALJ decision by the Departmental Appeals Board, Appellate Division in writing within 60 days from the ALJ decision. The DAB’s decision is the final administrative decision in the revocation appeal process. If the DAB’s decision is unfavorable, the provider may seek judicial review in a United States District Court by filing a civil action within 60 days from the DAB decision.

111 The re-enrollment bar does not apply in the event a revocation of Medicare billing privileges is imposed based upon a provider or supplier’s failure to respond timely to a revalidation request or other request for information. 112 A revoked provider or supplier must, within 60 calendar days after the effective date of revocation, submit all claims for items and services furnished before the date of the revocation letter. HHAs are the exception. A revoked HHA must submit all claims for items and services within 60 days after the later of the following: (1) effective date of the revocation or (2) the date that the HHA’s last payable episode ends. 113 See 42 C.F.R. § 424.545. 114 See 42 C.F.R. Part 498, Subpart A. 115 When appealing at the reconsideration level, the provider must submit any additional information that it wishes for the hearing officer to consider or it may be precluding from submitting that information later in appeal. 116 The ALJ is limited to deciding whether CMS had the authority to revoke the provider.