The revocation of a physician’s privileges by Medicare is a serious administrative action that can significantly impact a physician’s ability to practice. This process generally occurs when a physician is found to be non-compliant with Medicare standards or involved in fraudulent activities, abuse, or other misconduct. It can also arise for incomplete or captive application documents. Below is an overview of how this process typically unfolds.
Introduction to Medicare Privileges and Enrollment:
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Physicians and other healthcare providers must be enrolled in Medicare to be reimbursed for services provided to Medicare beneficiaries. Enrollment is managed by the Centers for Medicare & Medicaid Services (CMS), and providers must meet specific qualifications and follow Medicare’s rules and regulations. Providers apply through the Medicare Provider Enrollment, Chain, and Ownership System (PECOS), submitting information about their practice, credentials, and compliance with Medicare requirements. Once enrolled, providers must regularly revalidate their enrollment to ensure compliance with Medicare standards. This typically occurs every five years for physicians.
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Causes for Revocation of Medicare Privileges:
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Medicare may revoke a physician’s privileges for a variety of reasons, including:
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- submission of false claims or fraudulent billing practices (e.g., billing for services not provided),
- failure to comply with Medicare’s enrollment requirements or policies, such as updating provider information or maintaining proper documentation,
- if a physician is excluded from participating in federal health programs under Section 1128 of the Social Security Act (e.g., for criminal convictions related to healthcare fraud),
- if a physician's actions directly cause harm to patients or result in substandard care,
- if a physician’s state medical license is suspended or revoked, and
- incomplete application or failure to disclose a conviction.
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The Revocation Process:
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The revocation process follows specific steps, including notification, the opportunity for a corrective action plan, and appeals.
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Step 1: Notice of Revocation. If Medicare identifies a reason to revoke a physician’s privileges, it will issue a notice of revocation. The notice outlines the reason for the revocation, the effective date of revocation, and the physician’s rights to appeal the decision. The revocation is often effective 30 days after the notice is issued, but in some cases involving fraud or patient harm, the revocation may be immediate. Once revoked a physician has 90 days to request reconsideration. If that is denied, there is a two-step appeals process within the Medicare system, and if that fails, a final appeal to a constitutional federal court is an option.
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Step 2: Corrective Action Plan (CAP). Physicians are often given the opportunity to submit a CAP if the revocation is due to non-compliance (but not for fraud or criminal behavior). A CAP allows the physician to explain how they plan to correct the issue that led to the revocation. Medicare will review the CAP and decide whether to reinstate the physician’s privileges or proceed with the revocation. The CAP must be submitted within 30 days of receiving the revocation notice. If CMS accepts the CAP, the physician’s enrollment may be reinstated, potentially with oversight or conditions.
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Step 3: Appeals Process. If the revocation stands, the physician may appeal the decision through the Medicare appeals process. The first step is a request for reconsideration by a CMS contractor, which must be filed within 90 days of the revocation notice. If the reconsideration decision is unfavorable, the physician can request a hearing before an administrative law judge (ALJ) within 60 days. The ALJ reviews the case de novo (fresh review). If the ALJ decision is still unfavorable, the physician can appeal to the Medicare Appeals Council. And as a last resort, the physician can appeal to a United States District Court.
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Consequences of Revocation:
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When Medicare revokes a physician’s privileges the physician is barred from billing Medicare for services provided to Medicare beneficiaries. The revocation lasts for 1 to 3 years, depending on the severity of the offense. Although, in some cases, CMS can impose a lifetime ban. The physician’s information is entered into the CMS Preclusion List, which is shared with other payers, potentially impacting the physician’s ability to bill other federal health programs like Medicaid. The preclusion period could run for up to ten years and in a medical world where treating Medicare and Medicaid patients is crucial, preclusion could destroy a doctor’s career.
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Re-enrollment After Revocation:
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After the period of revocation expires, the physician may apply for re-enrollment in Medicare. However, re-enrollment is not guaranteed, and the physician must demonstrate compliance with all Medicare rules and regulations. CMS may impose additional scrutiny or conditions for re-enrollment.
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Mitigating Risk:
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Physicians can take steps to avoid revocation of privileges by maintaining accurate and up-to-date information in PECOS, complying with Medicare’s billing and documentation requirements, regularly revalidating their enrollment, and adhering to ethical standards and avoiding fraudulent practices.
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Conclusion on Physician's Revocation of Privileges by Medicare
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The revocation of a physician’s Medicare privileges is a serious administrative action that can stem from fraud, non-compliance, or other significant issues. The process includes notification, the opportunity for corrective actions, and an appeals process. Physicians facing revocation must respond quickly and strategically to preserve their ability to participate in Medicare and avoid broader consequences for their practice.
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Feel free to reach out if you need more specific information or further clarification.
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Weitz Morgan is a leading law firm in Texas in providing comprehensive advice and counsel to physicians. With a deep understanding of the unique challenges and complexities faced by this type of specialized practice, our team of experienced attorneys is dedicated to helping physicians navigate the legal landscape successfully.
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We recognize that physicians operate in a highly regulated environment, which necessitates a multifaceted approach to representation. Our firm offers a comprehensive set of services, including litigating board complaints and Medicare/Medicaid revocations, tailored to meet the specific needs of doctors in Texas, ensuring compliance, mitigating risks, and most importantly protecting licenses.
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