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Guide to the National Practitioner Data Bank, Revocation, and Appeals

The National Practitioner Data Bank (NPDB) is a database meant to facilitate easy access to reports of medical malpractice and adverse actions taken in response. All healthcare professionals should be aware of the impact that an NPDB report can have on their careers.

While the reports are not made available to the general public, they can be accessed by hospitals, licensing boards, professional societies, and other healthcare institutions, who may then refuse to work with you due to a report. The database’s scope is national, so you cannot avoid the effects of previous actions by practicing in another state.

In this article, you will learn about Medicare revocation, an action reportable to the NPDB, and how to navigate the appeals process.

Top Reasons for Medicare Revocation

There are 14 main reasons for Medicare revocation by the CMS, detailed in 42 CFR §424.535(a) of the Code of Federal Regulations. These reasons are:

1. Noncompliance: The provider has violated an enrollment requirement that applies to its provider type and hasn’t presented a corrective action plan (CAP). Alternatively, the provider has not paid applicable user fees.
2. Medicaid Termination: The applicable state Medicaid agency revoked or terminated the provider’s Medicaid billing privileges.
3. Abuse of Billing Privileges: The provider submitted a claim for services that realistically could not have been provided to the specified individual on the indicated date of service. Examples include: the beneficiary or physician was out of the city, state, or country when services were furnished, the beneficiary is already deceased, or the required equipment for testing was absent where testing occurred.
4. Misuse of Billing Number: The provider intentionally sold or allowed their Medicare billing number to be used by a different individual or entity. A valid reassignment or change in ownership is exempt.
5. False or Misleading Information: The provider gave false or misleading information on their enrollment application and certified it as “true.”
6. Felonies: The provider (including any managing employees or owners) was convicted of a state or federal felony prior to enrollment or renewal of enrollment if the conviction was within a 10-year period.
7. On-Site-Review: An on-site review or other reliable evidence has led the CMS to determine that the provider fails to meet certain enrollment requirements or has already ceased operation.
8. Provider or Supplier Conduct: The provider is denied access from Medicare, Medicaid, and any other federal healthcare program.
9. Improper Prescribing Practices: The provider has a history of prescribing drugs (covered under Medicare Part D) in a manner that poses a threat to the safety and health of their clients. Alternatively, the provider’s manner of prescribing drugs has failed to meet stated Medicare requirements.
10. Prescribing Authority: The provider’s DEA (Drug Enforcement Administration) registration has been revoked or suspended. Alternatively, the provider’s authority to prescribe drugs was revoked or suspended by the relevant state licensing board or other administrative body.
11. Initial Reserve Operating Funds: The HHA was unable to provide supporting documents that verify that they meet the requirement for initial reserve operating funds found in 42 CFR §489.28(a), within 30 days of a request for documentation.
12. Grounds Related to Provider and Supplier Screening Requirements: This is applicable only to institutional providers. The provider failed to submit the hardship exception request or application fees for their Medicare revalidation application. Alternatively, the provider failed to submit the relevant application forms or application fees within 30 days of their hardship exception being denied.
13. Failure to Document or Provide CMS Access to Documentation: This is applicable to providers or physicians that furnish, order, or certify the following: covered ordered DMEPOS items, items for imaging services, clinical laboratory items, or certified home healthcare services. The provider did not comply with the documentation or CMS access requirements specified in 42 CFR §424.516(f).
14. Failure to Report: This is applicable to physicians, non-physician healthcare practitioners, and their organizations. The provider did not comply with the reporting requirements specified in 42 CFR §424.516(d)(1)(ii) and (iii) — reporting any changes in practice location or any adverse legal actions against the provider within 30 days.

What Is the Medicare Revocation Appeals Process?

Medicare revocation is detrimental to healthcare practitioners. Even if you have not been intentionally dishonest in your practice, you may still face a revocation due to an oversight. Any provider whose Medicare enrollment has been revoked has the option of submitting an appeal to CMS. There are several levels to the process.

Submitting a Corrective Action Plan (CAP)

Under the Final Rule that took effect in February 2015, only providers who faced revocation for noncompliance could submit a CAP in order to appeal the decision. Providers are required to submit their CAP within a 30 day-period after the revocation notice. The CAP is required to contain demonstrable evidence that verifies the provider has corrected their noncompliance. If approved, the provider’s previous Medicare billing privileges will be returned, effective on the date that the provider became fully compliant with enrollment requirements. If denied, the provider has the option of submitting another appeal.

Reconsideration Stage

The first stage of the process for most providers is the reconsideration stage. Providers are required to submit an appeal within 60 days of the revocation notice. The appeal must contain all additional evidence or information that the provider wants their hearing officers to take into account. No additional information may be submitted at later stages unless the Administrative Law Judge (ALJ) deems it necessary.

Most appeals should be submitted to the provider’s Medicare Administrative Contractor (MAC) unless the reason for revocation falls under an abuse of billing privileges, in which case the CMS will handle the appeal.

Administrative Law Judge (ALJ) Hearing

If the reconsideration stage failed to yield the provider’s desired result, an ALJ hearing before the Departmental Appeals Board’s (DAB) Civil Remedies Division may be requested. The request for an ALJ hearing must be submitted within 60 days after the MAC or CMS made their reconsideration decision. During the hearing, the provider and a CMS attorney present written arguments, evidence, and testimony. Based on the material presented by both parties, the ALJ will issue their decision regarding whether or not the CMS’ revocation authority was applicable in the situation.

Departmental Appeals Board (DAB) Hearing

In the event that either the provider or CMS is unsatisfied with the ALJ’s decision, they have the right to request a review from the DAB’s Appellate Division. This request must be submitted within 60 days of the ALJ’s decision. Within the appeal process, DAB has the final administrative decision.

If the provider is still unsatisfied with the DAB’s decision, they may choose to go to a United States District Court and file a civil case. This must be filed within 60 days of the DAB’s decision.

Medicare Revocation and Appeals FAQs

What Can I Do If I Receive a Medicare Revocation Notice?

In most scenarios, the revocation will take effect 30 days after the revocation notice has been sent. During this time, it is in your best interest to begin the appeals process and speak to a lawyer who can help you build your case.

How Long Do I Need To Wait Before Re-enrolling If My Billing Privileges Were Revoked?

You typically need to wait one to three years after the date of revocation. The specific period will depend on the re-enrollment bar instituted by CMS. You are not allowed to re-enroll during this period.

Can I Submit Claims for Services Furnished Before My Billing Privileges Were Revoked?

While you are not allowed to submit claims for services furnished after revocation, you may still submit claims for prior services. However, you must submit these within 60 days of the revocation.

If your appeal was approved, and your privileges are retroactively reinstated, you can submit claims for services furnished during the revocation period.

Protect Your Practice with Legal Representation

It can be difficult to ensure that you and your group are always in compliance with Medicare enrollment requirements. If you are ever in need of assistance in appealing a revocation or simply have questions about compliance, feel free to contact us at Fenton Jurkowitz Law Group.