Tag Archives: Centers for Medicare and Medicaid Services (CMS)

Physician Payment Sunshine Act Deadline is Here-Are You Ready?

GFI Blog LabelBy George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law and Lance O. Leider, J.D., The Health Law Firm

As of August 1, 2013, the Physician Payment Sunshine Act (Sunshine Act) goes into effect. The Sunshine Act, contained in Section 6002 of the Patient Protection and Affordable Care Act (PPACA), is designed to highlight the financial relationship between doctors and the manufacturers of medical devices and pharmaceuticals. The act requires that light be shined on the payments being made to physicians by pharmaceutical and medical device manufacturers, bringing these out into the “sunshine.”

Some of the items tracked include gifts worth more than $10, five-star dinners, trips, money paid to physicians for speaking engagements, etc. The medical device and pharmaceutical manufacturers will be responsible for reporting the figures to the Centers for Medicare and Medicaid (CMS). However, it’s important that physicians keep their own records to verify the accuracy of the reports.

To read a summary of the Sunshine Act, click here.

What Has to be Reported and What Does Not Have to Be Reported.

All manufacturers of pharmaceuticals and medical devices will have to disclose how much money they pay physicians and hospitals in cash and gifts, as well as how much stock doctors and their families own in the particular manufacturer’s company.

As required by law, this information will be published by CMS starting in September 2014. There are several reporting exceptions, such as gifts less than $10, drug samples for patients and educational materials given to patients, according to a Huffington Post article.

To read the entire Huffington Post article, click here.

Physicians Need to Track Their Records.

The burden of collecting and reporting data will be the responsibility of the manufacturers of medical devices and pharmaceuticals, but physicians are encouraged to keep their own records. They will have 45 days to review disclosures and seek corrections if they dispute what is being reported. According to Modern Healthcare, CMS will not mediate disagreements but will note if a figure is being disputed.

Physicians can register with CMS starting January 1, 2014, to receive a consolidated report on activities each June for the prior reporting years.

To read the Modern Healthcare article, click here.

Helpful Resources for Physicians.

The Sunshine Act affects all physicians with a current medical license. The American Medical Association (AMA) has a “Physician Sunshine Act Tool Kit” available on its website to help physicians navigate the Sunshine Act changes. The AMA is also working on tools to aid physicians in talking with their patients about the transactions included in the new Sunshine Act database. Click here to access the AMA’s Physician Sunshine Act Tool Kit.

CMS is holding a national provider conference call on August 8, 2013. Doctors of medicine, osteopathy, chiropractic medicine, dentistry, dental surgery, optometry and podiatry are encouraged to participate and ask questions. CMS also recently introduced a free mobile app called “Open Payments Mobile for Physicians.” The app will help physicians and businesses track financial relationships.

Contact Health Law Attorneys Experienced in Representing Health Care Professionals.

The Health Law Firm routinely represents pharmacists, pharmacies, physicians, nurses and other health providers in investigations, regulatory matters, licensing issues, litigation, inspections and audits involving the Drug Enforcement Administration (DEA), Federal Bureau of Investigation (FBI), Department of Health (DOH) and other law enforcement agencies. Its attorneys include those who are board certified by The Florida Bar in Health Law as well as licensed health professionals who are also attorneys.

To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

Comments?

What are your concerns about the Sunshine Act? Are you ready for the law to go into effect? How have you prepared for the Sunshine Act? Please leave any thoughtful comments below.

Sources:

Robeznieks, Andis. “Reform Update: Aug. 1 Brings Deadline to Report Physician Payments.” Modern Healthcare. (July 29, 2013). From: http://www.modernhealthcare.com/article/20130729/NEWS/307299967/reform-update-aug-1-brings-deadline-to-report-physician-payments

Aronfeld, Spenser. “Here Comes the Sunshine Act – And It’s All Right.” Huffington Post. (July 16, 2013). From: http://www.huffingtonpost.com/spencer-aronfeld/here-comes-the-sunshine-act_b_3595394.html?view=print&comm_ref=false

Lasher Todd, Heather. “AMA Reminds Physicians: Sunshine Act Reporting Starts This Week.” American Medical Assocations. (July 30, 2013). From: http://www.ama-assn.org/ama/pub/news/news/2013/2013-07-30-sunshine-act-reporting-this-week.page

About the Authors: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

Lance O. Leider is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Avenue, Altamonte Springs, Florida 32714, Phone:  (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.
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CMS Fights Medicare Fraud With Ban on New Home Health Agencies and Ambulance Suppliers in Three Cities

LOL Blog Label 2

By Lance O. Leider, J.D., The Health Law Firm and George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

The Centers for Medicare and Medicaid Services (CMS) announced it will temporarily ban new home health providers and ambulance suppliers from enrolling in Medicare, Medicaid and the Children’s Health Insurance Program (CHIP) in three fraud “hot spots.” According to CMS, the six-month moratorium begins July 30, 2013. It applies to newly enrolling home health agencies (HHAs) in Miami, Florida, and Chicago, Illinois. It also applies to newly enrolling ambulance suppliers in Houston, Texas. Existing providers and suppliers can continue to deliver and bill for services. The goal of the ban is to fight healthcare fraud.

Click here to read the press release from CMS.

Authority to impose a moratorium was included in the Patient Protection and Affordable Care Act (PPACA). According to a summary of the anti-fraud provisions in the Affordable Care Act, the Act allows CMS to prohibit new providers from joining the program where necessary to prevent or fight fraud, waste or abuse in certain geographic areas or for certain categories of services. This is the first time CMS is exercising its authority.

Why Moratorium Was Imposed in These Areas.

According to CMS, the decision to impose the moratorium was based on a number of factors, including a disproportional number of providers and suppliers relative to beneficiaries, a quick increase in enrollment applications from providers and suppliers, and extremely high utilization in these areas.

Miami Area a Hot Bed for Healthcare Fraud and Abuse.

The Miami area has stood out as one of the nation’s hubs of Medicare fraud, according to CMS. For example, in May 2013, a Miami patient recruiter for an HHA was sentenced to 37 months in prison for participating in a $20 million Medicare fraud scheme. Click here to read a previous blog. In that same month, workers from a Miami-area HHA were accused of bribing Medicare beneficiaries for their Medicare information, which was used to bill for home health services that were never rendered or not medically necessary. To read more, click here.

According to the Miami Herald, with a large number of elderly Medicare beneficiaries living in Miami, it’s not a surprise that healthcare fraud is so prevalent. South Florida allegedly accounts for one-third (1/3) of all healthcare fraud prosecutions in the nation. Click here to read the entire Miami Herald article.

The Affordable Care Act Offers the Government New Tools to Fight Healthcare Fraud.

In 2011 and 2012, the government reported recovery of $14.9 billion in healthcare fraud judgments, settlements and administrative impositions, according to CMS. In addition, CMS has revoked 14,663 providers and suppliers’ ability to bill the Medicare Program since 2011. The Affordable Care Act seeks to improve anti-fraud and abuse measures by focusing on prevention rather than the traditional “pay-and-chase” model of catching crooks after they have committed fraud. Click here to read a blog on the Affordable Care Act’s other fraud fighting tools.

What This Means for Health Care Professionals and Providers.

By knowing the government is beefing up measures to fight healthcare fraud, providers can attempt to avoid practices that are likely to lead to Zone Program Integrity Contractor (ZPIC) or Recovery Audit Contractor (RAC) audits. Additionally, a provider can be prepared for potential audits by increasing its documentation and compliance efforts.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.
For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Comments?

What do you think of CMS’ decision to invoke the moratorium? Do you think this should have been done sooner? Please leave any thoughtful comments below.

Sources:

Centers for Medicare and Medicaid Services. “CMS Imposes First Affordable Care Act Enrollment Moratoria to Combat Fraud.” CMS.gov. (July 26, 2013). From: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2013-Press-Releases-Items/2013-07-26.html

Chang, Daniel. “Feds Ban New Home Healthcare Agencies in Miami to Fight Medicare Fraud.” Miami Herald. (July 26, 2013). From: http://www.miamiherald.com/2013/07/26/3524612/feds-ban-new-home-healthcare-agencies.html

Beasley, Deena. “U.S. Bans New Home Health, Ambulance Providers in Three Regions.” Miami Herald. (July 26, 2013). From: http://www.reuters.com/article/2013/07/26/us-medicare-moratoria-idUSBRE96P14P20130726

About the Authors: Lance O. Leider is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Altamonte Springs, Florida 32714, Phone: (407) 331-6620.

George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

 

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.

Cardiologists Face Higher Scrutiny by CMS

Lance Leider headshotBy Lance O. Leider, J.D., The Health Law Firm

As the U.S. population ages and heart disease continues to be a leading cause of health issues, cardiologists and cardiology practices are finding themselves billing Medicare for more and more visits and procedures.

Along with that increase in reimbursement from Medicare comes an increase in scrutiny.  According to the Centers for Medicare and Medicaid Services (CMS), more than sixteen percent (16%) of total Medicare spending in 2010, was for cardiovascular care.

Some experts predict that this number will increase as cardiologists continue to adopt state-of-the-art technology and procedural techniques when treating their patients.

All of this means that whistleblowers, Recovery Audit Contractor (RAC) auditors, Zone Program Integrity Contractor (ZPIC) auditors, and CMS’s data mining services are going to be more incentivized to come after cardiovascular reimbursements.

To read more on the high scrutiny cardiologists face, click here to read an article on Modern Healthcare.

The Audits Are Coming.

Cardiology physicians and practices need to understand that just because they are doing things the “right way” does not mean that they will not be the subject of an audit. Auditing can be triggered by any number of things ranging from disgruntled employees, competing practices, dissatisfied patients, random audits, above average billing for certain codes, etc. None of these triggers means that a practice is doing anything wrong, but it will have to face an audit nonetheless.

Being prepared before an audit happens can be the most effective defense.  Review some of these prior articles and blogs we have written for tips in establishing audit protocols and handling audits in general:

–  Self Audit Now to Save Your Practice Later
–  Responding to a Medicare Audit – Practice Tips
–  Checklist on What to Do When Notified of a ZPIC or Medicare Audit and Site Visit – Part 1
–  Checklist on What to Do When Notified of a ZPIC or Medicare Audit and Site Visit – Part 2

The Best Defense for an Audit is to be Prepared Before an Audit Happens.

So long as CMS employs a “pay and chase” method of reimbursement, audits will be a permanent part of the healthcare landscape.  Every medical practice should consult with an attorney experienced in handling Medicare, Medicaid and other third party audits in order to develop effective policies and procedures.  By preparing for an audit prior to its occurrence a practice is in the best position to avoid any kind of sanction or overpayment demand.

Don’t Wait Until It’s Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

Comments?

Do you think cardiologist and cardiology practices are under a higher amount of scrutiny? Please leave any thoughtful comments below.

Sources:

Carlson, Joe. “Cardiologists Enmeshed in High-Scrutiny Climate.” Modern Healthcare. (July 8, 2013). From: http://www.modernhealthcare.com/article/20130708/BLOG/307089995/cardiologists-enmeshed-in-high-scrutiny-climate

About the Author: Lance O. Leider is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Avenue, Altamonte Springs, Florida 32714, Phone:  (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999. Copyright © 1996-2012 The Health Law Firm. All rights reserved.

Florida Pharmacy Owner Accused of Medicare Fraud

00011_RT8By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

A family that owns a number of South Florida pharmacies is allegedly under investigation for Medicare fraud, according to a number of sources. On January 17, 2013, federal authorities raided one pharmacy location in Naples, Florida. Drug Enforcement Administration (DEA) agents removed boxes of documents and computers from the pharmacy, according to Naples News. The pharmacy owner and his mother are allegedly being investigated by the U.S. Office of Inspector General (OIG) of the Department of Health and Human Services (HHS).

Click here to read the entire Naples News article.

Pharmacy Owner and Mother Allegedly Submitted False Claims to Medicare, Medicaid and Tricare.

According to NBC2, a South Florida television station, the pharmacy owner and his mother were both allegedly part of a scheme that defrauded Medicare. The family allegedly submitted claims to Medicare Part D after beneficiaries had died. This information came from a letter sent to Medicare Part D providers from the Centers for Medicare and Medicaid Services (CMS) on October 17, 2012. The letter was obtained by NBC2. The scheme allegedly also involved submitting false claims to Medicaid and Tricare.

Click here to watch the NBC2 news story.

Investigation is Ongoing.

The pharmacy that was raided is part of a chain of stores owned by the same family. So far, only the pharmacy located on Rattlesnake-Hammock Road in Naples is being investigated. That location is reportedly still closed, but the other pharmacy locations are open.

Neither the DEA nor the OIG of the HHS has released a press release on this investigation.

As in all media reports, please remember that all persons are presumed to be innocent until proven guilty in a court of law.

Pharmacies Are Being Raided and Shutdown  All Over the State.

If  you have watched the news at all lately or have been reading our blog, you can tell there have been an increased number of raids on pharmacies, arrests of pharmacists and emergency suspension orders issued from the Department of Health (DOH).

Recently, the DEA served a Walgreens distribution center in Florida with an immediate suspension order (click here to read more on this story), and pulled the controlled substance licenses from two Central Florida CVS Pharmacies (to learn more, click here).

In my personal opinion, the recent raids and investigations at pharmacies are especially hard on the independent operators. If the large retail giants can’t survive, the small independent pharmacies stand little chance.

Talk with an Experienced Health Law Attorney About Medicare, Medicaid and Tricare Issues Now.

The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620 or (850) 439-1001.

What Do You Think?

As a pharmacy owner, pharmacy employee or health care facility owner, what do you think of the increased effort to find fraud? Do you think all facilities, not just pharmacies, are under the microscope? Please leave any thoughtful comments below.

Sources:

Freeman, Liz. “Sunshine Pharmacy in East Naples Remains Close, Day After Federal Raid.” Naples News. (January 19, 2013). From: http://www.naplesnews.com/news/2013/jan/19/sunshine-pharmacy-east-remains-closed-raid-federal/

Ritter, Rick. “Naples Pharmacy Busted for Medicare Fraud.” NBC2. (January 20, 2013). From: http://www.nbc-2.com/story/20627104/detectives-investigating-medicare-fraud-at-naples-pharmacy

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone:  (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.

Copyright © 1996-2012 The Health Law Firm. All rights reserved.

Medicare Put the Hospice Industry Under the Microscope

Patricia's Photos 013By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

It’s no surprise to anyone that Medicare is cracking down on hospices around the country. According to a report by the Office of Inspector General (OIG), eighty-two percent (82%) of hospices’ claims did not meet Medicare coverage requirements. That is why Medicare is investigating the industry as a whole. Specific details on what Medicare is looking for can be found in the 2013 OIG Work Plan. Click here to read the 2013 OIG Work Plan.

So far, Medicare has kept true to its word. During the week of January 7, 2013, the federal government announced it is suing a Central Florida hospice for Medicare fraud, according to the Orlando Sentinel. (Click here to read the Orlando Sentinel article.) Also, one of the nation’s largest and most respected hospices located in San Diego, California, is in the middle of a federal audit, according to a Kaiser Health News article. (Click here to read the Kaiser Health News article.) These are just a few examples of what hospices around the country are dealing with.

Central Florida Hospice Dealing with Qui Tam or Whistleblower Case.

The federal qui tam (whistleblower) lawsuit against the Central Florida hospice was reportedly filed by the hospice’s former vice president of finance in September 2011. The Department of Justice (DOJ) joined the whistleblower lawsuit in September of 2012.

The federal lawsuit alleges the hospice CEO ordered employees to admit patients without properly determining whether they were terminally ill, as required by Medicare. Staff was also apparently told to find ways to “edit” patients’ medical files so that the billing appeared legitimate. To learn more on this case, click here to read a blog I wrote on the hospice when the government joined the lawsuit. Click here to read the entire whistleblower complaint.

San Diego Hospice Cuts More Than Just Patients After Medicare Audit.

In 2010, federal officials audited a large hospice located in San Diego, California. Medicare is still investigating the hospice’s 2009-2010 admissions. Since the audit, the hospice has had to drop around 400 patients, due to their ineligibility for hospice care. Cutting patients meant a decrease in profits, which subsequently meant the hospice had to let 260 employees go and close a 24-bed hospital, according to Kaiser Health News.

Hospices Under Scrutiny.

According to the Kaiser Health News article, the hospice industry is booming. In 2011, it’s estimated hospices served 1.65 million people in the U.S., which is about forty-five percent (45%) of all those who died that year. Medicare paid for the hospice benefits of eighty-four percent (84%) of those patients.

Medicare is concerned with the amount of people hospices admit. Hospices normally treat patients with fewer than six months to live. If a patient recovers, Medicare expects the patient to leave the program. Patients may stay in hospice care only if they are re-certified as still likely to die within six months by a physician. It’s thought that enrollment bonuses to employees and kickbacks to nursing homes that refer patients are big factors as to why hospices accept ineligible patients.

Medicare Trying to Keep Up with Fraud and Abuse in Hospice Industry.

Currently, the Centers for Medicare and Medicaid Services (CMS) is focused on safeguarding tax payers dollars from fraud. I have recently seen a number of audits initiated against health professionals who treat assisted living facility (ALF), hospice and skilled nursing facility (SNF) residents. Most often these are audits by the Medicare Administrative Contractor (MAC), because these facilities have been identified as fraught with fraud and abuse. I wrote a two-part blog this topic. Click here for part one and here for part two.

If you are being audited, click here to read some tips we recommend in responding to a Medicare audit.

Contact Health Law Attorneys Experienced in Handling Medicaid and Medicare Audits.

The Health Law Firm’s attorneys routinely represent physicians, medical groups, clinics, pharmacies, nurses, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions.

To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.

What Do You Think?

What do you think about Medicare targeting hospices? Do you think it is necessary? Is the hospice business going to suffer because of these investigations? Please leave any thoughtful comment below.

Sources:

Santich, Kate. “Feds Sue Hospice of the Comforter for Medicare Fraud.” Orlando Sentinel. (January 14, 2013). From: http://www.orlandosentinel.com/news/local/breakingnews/os-feds-sue-hospice-of-the-comforter-20130114,0,7827264.story

U.S. ex rel. Stone v. Hospice of the Comforter, Inc., No. 6:11-cv-1498-ORL-22-AAB (M.D. Fla) United State District Court for the Middle District of Florida Orlando Division. (September 12, 2012), available at http://www.thehealthlawfirm.com/uploads/US%20v%20Hospice%20of%20the%20Comforter.pdf

Dotinga, Randy. “Slowly Dying Patients, Am Audit and A Hospice’s Undoing.” Kaiser Health News. (January 16, 2013). From: http://www.kaiserhealthnews.org/Stories/2013/January/16/san-diego-hospice.aspx

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

 

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.

Copyright © 1996-2012 The Health Law Firm. All rights reserved.

Compliance with Conditions of Participation Necessary for Reinstatement of Terminated Medicare Billing Privileges or Revoked Medicare Provider Number and Participation Agreement

By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

We have recently experienced an alarming increase in the number of Medicare providers receiving notices that their Medicare billing privileges are being terminated.  These include home health agencies (HHAs), independent diagnostic testing facilities (IDTFs), ambulance and emergency transport providers, physicians, pharmacies, durable medical equipment (DME) providers, medical groups, physical therapists and therapy providers.  In most cases, this is because the health care provider has failed to update its address with the Medicare Program.  To see a prior article we wrote on this, click here.

Most often this occurs when a site visit by the Medicare administrative contractor (MAC) (previously called the carrier or fiscal intermediary) arrives at the business location on file with Medicare and finds the provider’s business location has changed.  Other times the termination is because of a minor technical violation of Medicare rules, such as being closed when a site inspector shows up, failing to have hours of operation posted, failing to have a required insurance policy in place, failing to be open at the time the inspector shows up, or other similar reasons.

If the health provider does nothing to appeal the revocation, then there is a required waiting period of at least one year before it can even reapply to the Medicare Program.  The termination may also have extremely serious consequences regarding participation in the state Medicaid Program, licensure, other contracts, clinical privileges, participation on insurance provider panels and related businesses.

We recommend immediately retaining an experienced health attorney to help you prepare and file a corrective action plan (CAP), request for reconsideration of the decision and an appeal, if necessary.  We recommend that you include proof of currently meeting every required condition of participation (COP) for your health specialty, service or item.  We include copies of written policies adopted, new forms, new procedures, insurance policies, copies of CMS forms 855 that were previously submitted, and other documents that may be required by the COP.  Please see our prior blog/article on submitting CAPs.

For access to each of the conditions of participation (COP) and conditions for coverage (CFC), click on the following link, or cut and paste it into your internet browser:

http://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/index.html?redirect=/CFCsAndCoPs/

About the Author:  George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law.  He is the President and Managing Partner of The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida, area.  www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone:  (407) 331-6620.