Appealing a Medicare or Medicaid revocation

Medicare and Medicaid are critically important to many medical providers in Texas. Being denied the ability to bill for these patients would mean a substantial loss of income to many clinics, possibly forcing them to close. Unfortunately, the revocation of Medicare and Medicaid contracts is if anything becoming more common.

If this happens to your facility, there is a process of appealing the decision. It may be possible to have it reversed or, in some cases, even move to a corrective action settlement. Time is of the essence, however, and expertise in the somewhat arcane process is critical for success.

Revocation of contract

All Medicare and Medicaid contracts are administered by the Centers for Medicare & Medicaid Services (CMS). While they have been focusing their attention on review of contracts and bills submitted rather than corrective action against fraud later discovered, there are signs that they are stepping up their enforcement through revocation.

Revocation is the primary tool that CMS has to enforce compliance, and they use it heavily. Receiving a notice of revocation is often the first sign of concern for far too many healthcare providers, and it needs to be taken seriously immediately.

Appeals process

Time is of the essence when appealing a contract revocation with CMS. There is a 60 day window to file a request for reconsideration, starting with the date of revocation. In all cases except abuse of billing the appeal is conducted by the Medicare Administrative Contractor (MAC).

If the revocation was for noncompliance, a Corrective Action Plan (CAP) may be authorized. Non-compliance issues include lapsed licenses, missing address, and similar sorts of things. If the revocation was for a reason which can be attributed to non-compliance it may be possible to have the contract reinstated with a CAP within 30 days. This can simplify the process dramatically.

If that is not the case, the reconsideration stage is critical in that it is the only opportunity to bring up mitigating factors and considerations. The process includes some room for dialogue and discussion, unlike later stages of the process.

If the reconsideration is not decided in your favor, you can appeal to an administrative law judge. They will be able to decide only on the facts presented during reconsideration, and then only on whether CMS has the authority to revoke and not the special circumstances. It is much more technical at this point.

Time is of the essence

In all cases of Medicare and Medicaid contract revocation, time is definitely the most important consideration. Everything has to be in place within that 60 day window, or 30 day window for a CAP, in order to have a successful appeal.

This is why experience with health care law and these types of cases is absolutely critical for a successful conclusion. It is vital to many healthcare providers here in Texas that they not lose their Medicare and Medicaid billing privileges, but you have to act quickly and decisively when you are notified of revocation proceedings.

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