Tag Archives: Medicare provider number

Why Have You Received a Denial on Your Medicare Enrollment Application?

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

Did you receive a denial on your Medicare enrollment application and can’t figure out why? You may be surprised to find out that even the smallest punctuation error, such as a missing comma or period, could be the reason Medicare rejected your application.

The Centers for Medicare and Medicaid Services (CMS) will deny Medicare applications of physicians, medical groups, home health agencies (HHAs), pharmacies and durable medical equipment (DME) suppliers because the name on file with the National Plan & Provider Enumeration System (NPPES) is not the same legal business name as reported to the Internal Revenue Service (IRS). The use of punctuation marks and abbreviations in your name with NPPES could produce a no match in the CMS records. It is imperative when filling out the Medicare enrollment forms that you use the exact legal business name on file with the IRS.

The easiest way for a health care provider or facility to apply for enrollment or make changes to enrollment information is to use the internet-based Provider Enrollment Chain and Ownership System (PECOS). Click here to utilize PECOS.

Other Reasons Why a Medicare Enrollment Application can be Denied.

Here are some more situations that can cause a provider’s application to be denied:

1. The form CMS-855 or PECOS certification statement is unsigned; is undated; contains a copied or stamped signature; or for the paper form CMS-855I and form CMS-855O submissions, someone other than the physician or non-physician practitioner signed the form.
2. The submitted paper application is an outdated version.
3. The applicant failed to submit all of the forms needed to process a reassignment package within 15 calendar days of receipt.
4. The form CMS-855 was completed in pencil.
5. The wrong application was submitted (for example: a form CMS-855B was submitted for Part A enrollment).
6. If a web-generated application is submitted, it does not appear to have been downloaded from the CMS website.
7. The health care provider sent in an application or PECOS certification statement via fax or e-mail when he/she was not otherwise permitted to do so.
8. The health care provider failed to submit an application fee (if applicable to the situation).

Update All of Your Information with Medicare.

If you are already a Medicare provider, I urge you to personally go into the PECOS and NPPES and print out a copy of the existing information to check it.

If anything is incorrect, including an incorrect or incomplete name for your medical group, corporation or business, immediately fix this. Everything should be consistent. All of your state licenses and corporation/company information on file with your Secretary of State should also contain the same information as well.

Incorrect Information Could Lead to the Termination of Your Medicare Provider Number.

The consequences of not checking your information on file are severe, and can include termination of your Medicare provider number and billing privileges.

The effect of this termination includes:

– You are prohibited from reapplying to Medicare for at least two years.
– You may have to pay back any money received from the Medicare program since the effective date of the termination (often many months prior to the notification letter).
– Other auditing agents may be notified such as the Medicare Zone Program Integrity Contractors (ZPICs) and the state Medicaid Fraud Control Unit (MFCU).
– You may no longer contract with Medicare or anyone who does.
– You may and probably will be terminated from the approved provider panels of health insurance companies with which you are currently contracted.
– You may and probably will be terminated from skilled nursing facilities (SNFs) and HHAs with which you have contracts.
– You may and probably will have your clinical privileges terminated by hospitals or ambulatory surgical centers (ASCs).

To read our recommendations on what to do if your Medicare provider number is terminated, click here to read my previous blog.


Did you know that even the smallest punctuation errors could lead to a denial of your application for Medicare enrollment? Have you ever had an issue enrolling in the Medicare program? Please leave any thoughtful comments below.

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

The lawyers of The Health Law Firm routinely represent physicians, medical groups, clinics, pharmacies, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in Medicare and Medicaid investigations, audits and recovery actions. They also represent them in preparing and submitting corrective action plans (CAPs), requests for reconsideration, and appeal hearings, including Medicare administrative hearings before an administrative law judge. Attorneys of The Health Law Firm represent health providers in actions initiated by the Medicaid Fraud Control Units (MFCUs), in False Claims Act cases, in actions initiated by the state to exclude or terminate from the Medicaid Program or by the HHS OIG to exclude from the Medicare Program.

Call now at (407) 331-6620 or (850) 439-1001 or visit our website www.TheHealthLawFirm.com.

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.

Christopher E. Brown, J.D., 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 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 © 1996-2014 The Health Law Firm. All rights reserved.

Beware of These Illegal Business Arrangements in Healthcare

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

Florida does not have a corporate practice of medicine prohibition like many other states do.  In other words, a physician is allowed to work as an employee or independent contractor of a corporation or other business entity owned by nonphysicians   However, there are a number of exceptions to this rule.

For dentists, optometrists and chiropractors there are specific statutory prohibitions on any member of that profession practicing his or her specialty while working for a group, practice or organization that is owned or controlled by one who is not a member of that profession.  These laws, a different one for each specialty, make it a felony to do so, as well as grounds for discipline against the professional’s license.  It is considered to be a separate felony offense for each day.

The main exceptions for these prohibitions include, for example, working for a hospital, working for a federal health care clinic, working for a not-for-profit charity health care clinic, and other limited exceptions.

There are All Treated the Same: Revoked License, Licensed in Another State But Not in Florida and Suspended License.

We have seen cases in which a dentist or chiropractor licensed in another state, but not in Florida, owned or operated a dental or chiropractic clinic in Florida.  This would be prohibited, of course.

In other cases, we have seen health professionals who have had their licenses revoked continue to own and operate or even “lease out” their practices to others.  The ownership or control of the practice by one with a revoked license would also be illegal.

We have seen cases in which a spouse or child of a deceased physician has continued to own and operate a clinic after the health professional died, when he or she was not a health professional.  This is illegal from the day the health professional died and there is no “grace period.”

In the Cases of Health Care Clinics and Pain Management Clinics…

In cases in which a member of the profession is allowed to work for a group, practice, clinic, corporation or other business entity that is not owned by health professionals, then that organization (again, with certain exceptions) is required to obtain a health care clinic license from the Agency for Health Care Administration (AHCA).  Professionals other than dentists, chiropractors and optometrists, could work, for example, for a corporation (corp.) or limited liability company (LLC) owned by an accountant and a businessman, as long as it had a valid health care clinic license.  Owning, operating or working for an unlicensed health care clinic which would be required by Florida law to be licensed, is a felony offense.

If you are a physician, nurse practitioner, other licensed health professional, you need to check the business’s licensure status with AHCA to make sure it is current and valid, before going to work there.

Additional situations include pain clinics and other types of health practices which constitute “risky” areas of practice.  If you are not aware of the almost daily occurrences of physicians getting busted, pharmacists getting arrested, and pharmacies and pain clinics being searched, closed and shuttered, you’re not reading the newspapers or watching TV.  Usually pain clinics are required to be licensed as health care clinics by AHCA and as pain medicine clinics by the Department of Health (DOH).  However, a regular medical practice is exempt from those requirements (with certain exceptions, of course).

We have encountered situations where a good physician is recruited into a very questionable practice setting by unscrupulous nonprofessionals who are merely using him or her.  Everything is placed in the physician’s name.  On paper it appears the physician is running a legitimate medical practice.  However, behind the scenes, the physician actually controls nothing.  It is clear that the whole setup is just a shell, a phony medical practice set up to skirt the law and avoid licensure.

We have seen medical practices and dental practices where a nonprofessional business person has control of all of the billings and collections, the employees, the bank accounts and all of the records.  The physician does not have control of anything, not even the practice’s bank account.  We have encountered several situations where the physician does not even have passwords to his/her own computers and software or keys to his/her own office.  We believe that such situations are sham operations set up to avoid statutory requirements.  A physician would be well warned to stay away from such situations.

Beware of Scams to Avoid the Law.

We have seen many cases where individuals, including lawyers and business people, have attempted to get creative to come up with schemes to try to get around the laws.  Often there may be a legal way to create an arrangement between licensed health professionals and unlicensed business people, to accomplish their goals, especially related to financial arrangements.

However, we have also seen many such schemes that were clearly illegal and meant to just put a facade on an obviously illegal arrangement.  When the criminal authorities start to investigate the behind-the-scenes people disappear, leaving the physician to pay the price. A physician or health care provider should have any such business arrangement reviewed in detail by a board certified health lawyer before he or she gets involved with it.  If you are thinking about investing in such a practice or arrangement, then we strongly recommend that you obtain an opinion letter from a board certified health lawyer as to the legality of the situation or arrangement.

Do Not Let Anyone Else Use Your Billing Number or Medicare Provider Number.

We have also been consulted on a number of occasions by physicians who were contacted by business people starting clinics allegedly seeking a “medical director” for their clinic, offering the physician a large amount of money without having to perform any real work.  However, they just need to use the physician’s Medicare number to bill with for a few months until their Medicare number is approved.  Such enterprises usually turn out to be Medicare billing fraud schemes.  The company uses the physician’s Medicare number to bill for hundreds or thousands of physician patient visits in patient’s homes, nursing homes or assisted living facilities (ALFs) that never occur.  When Medicare stops paying and starts investigating, the ones behind the scheme disappear and leave the physician holding the bag.

Avoid such schemes.  Avoid any situation where someone else “needs” to use your Medicare number for services that you are not actually performing yourself.  If the deal sounds too good to be true, it probably is.  You will wind up paying a heavy price later on if you fall for it,

There are Many Illegal Situations Which Carry Heavy Consequences.

Many of the above situations can result in criminal prosecutions.  In addition, these are also usually grounds for discipline on a health professional’s license.  In many cases, all fees collected while operating illegally must be refunded.  In the case where pain management is involved, the penalties are much higher than in other situations.  Where Medicare and Medicaid patients or billings may be involved, the risks of criminal prosecution and very large monetary penalties are much greater.

Contact a Health Care Attorney Experienced in Negotiating and Evaluating Physician and Health Professional’s Business Transactions.

At the Health Law Firm we provide legal services for all health care providers and professionals. This includes physicians, nurses, dentists, psychologists, psychiatrists, mental health counselors, durable medical equipment suppliers (DME), medical students and interns, hospitals, ambulatory surgical centers, pain management clinics, nursing homes, and any other health care provider.

The services we provide include reviewing and negotiating contracts, preparing contracts, helping employers and employees enforce contracts, advice on setting aside or voiding contracts, litigation of contracts (in start or federal court), business transactions, professional license defense, opinion letters, representation in investigations, fair hearing defense, representation in peer review and clinical privileges hearings, litigation of restrictive covenant (covenants not to compete), Medicare and Medicaid audits, commercial litigation, and administrative hearings.

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 about this blog? Please leave any thoughtful comments below.

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.