Getting Reinstated and Off the Medicare Exclusion List

Close up of the header of a Medicare enrollment form and a pair of glasses.

Health care providers and companies that bill federal health programs may be receiving an outpouring of support, financial aid, and some temporary reprieve from normally restrictive regulations and requirements during COVID-19, but they are not receiving the same love from auditors on the lookout for waste, fraud, and abuse.

As the world continues to combat the novel coronavirus, and states like Texas implement waivers to cut through red tape and bolster the health care workforce, contractors for the Centers for Medicare and Medicaid Services (CMS) are continuing to audit claims and payment transactions involving Medicare beneficiaries. This includes big names like Qlarant Integrity Solutions, LLC and Novitas Solutions, Inc., which was recently awarded a monstrous Medicare Administrative Contractor (MAC) contract for Jurisdiction H (JH), the jurisdiction covering Texas and several other states.

With all the uncertainty surrounding the future of the pandemic, there is little surprise that many Medicare billers are keen on staying out of the crosshairs of contractors like Qlarant and Novitas – a task that requires comprehensive compliance plans, knowledgeable counsel, and the need to stay up-to-date with the evolving barrage of regulatory shake-ups.

It’s also no surprise, with the growing demand for health care services, that many providers, health care businesses, and suppliers want to:

  • Explore their options for re-enrollment in Medicare after an exclusion; and
  • Prevent Medicare exclusion and billing privilege revocation upon notice of audits or enforcement actions.

Seeking Reinstatement after Medicare Exclusion

As we discuss on our Medicare Exclusions & Revocations FAQ, there may be options for those already on the federal List of Excluded Individuals and Entities (LEIE).

Providers and health care companies who are not permanently barred can seek reinstatement of their Medicare billing privileges. However, you must apply for and be granted reinstatement by the OIG.

You may apply for Medicare reinstatement:

  1. Within 90 days of the date the exclusion period expires;
  2. Upon regaining a license implicated in an indefinite exclusion;
  3. Upon obtaining a different license in the same state / or the same license in another state; or
  4. After 3 years of exclusion without any license in any state.

In many cases, the passing of time without new or similar offenses will be one of the most important factors in seeking reinstatement. Depending on the circumstances surrounding the exclusion, other factors may need to be addressed, such as:

  • Repayment of an overpayment;
  • Payment of fines;
  • Payment of restitution.

Fines, restitution, and overpayments must be repaid, or scheduled to be repaid as part of a payment plan, for requests for removal from the LEIE to be favorably considered. Additionally, applicants will need to demonstrate they have not been working for or as a Medicare or Medicaid provider during the exclusion period.

Beyond these requirements, there are other ways reinstatement applicants can bolster their case. This may include:

  • Statements that you do not seek in work in a specific line of health care;
  • Submission of letters, testimonials, or other documentation showing rehabilitation;
  • Providing evidence of positive contributions to the community;
  • Letters illustrating how you intend to help beneficiaries and your community upon reinstatement, including assistance with COVID-19 care and containment efforts.

Medicare Reconsideration Requests

For those who are facing enforcement actions that may precede Medicare exclusion or revocation of billing privileges (i.e. audits that unveil practices or patterns of submitting claims that fail to meet Medicare’s requirements), there may also be options to avoid or mitigate adverse repercussions. These options, however, require early intervention.

If you receive a notice from Qlarant, Novitas, CMS, or another contractor or enforcement agency, mitigation efforts should be taken as soon as possible. Our team at Hendershot Cowart is available to immediately assist clients in evaluating their current circumstance and available options, and proceeding appropriately. This may include:

  • Complying with requests for documentation that support medical necessity or veracity of billing practices flagged by contractors in a manner that provides requested information while protecting providers / businesses.
  • Seeking reversal of billing privilege revocations based on convictions for revocable criminal offenses by terminating employment or contractual relationships with the convicted individual.
  • Developing and submitting a Corrective Action Plan (CAP) with evidence of current regulatory compliance within 30 days of a revocation notice. These plans must correct cited deficiencies thoroughly, and can be developed prior to or concurrent with an appeal.
  • Requesting reconsideration in writing within 60 days of a revocation notice. Reconsideration requests may be submitted to CMS, in cases of abusive billing practices, or to the MAC.

Reconsideration allows providers and businesses to submit documentation to be considered with an appeal (often their last opportunity to do so) and benefit from CMS’ discretionary power to consider other circumstantial or mitigating factors, such as a provider’s location and beneficiaries’ access to care, the nature of services or supplies provided by a business or health care practice, and more.

In light of the COVID-19 pandemic, and the need to increase health care capacity and workforce, these types of factors may provide opportunity for favorable consideration and resolution of enforcement actions before they progress to ALJ hearings, DAB hearings, or federal judicial review, or result in billing privilege revocation or program exclusion. Still, because a request for reconsideration must state issues or findings of fact with which you disagree, and the reasons for your disagreement, they should be crafted carefully with the assistance of experienced attorneys.

Proven Health Care Attorneys: From Proactive Compliance to Responsive Mitigation Efforts

From proactive and preventative compliance measures to immediate support with enforcement action response efforts, Hendershot Cowart P.C. provides comprehensive counsel to protect our clients’ futures.

Our health and medical law team extensive experience in Medicare and health care compliance matters, and has been closely tracking developments associated with COVID-19 that impact our clients and their cases. Based in Houston, we serve providers, practices, and businesses, including Durable Medical Equipment (DME) suppliers, throughout Texas and the nation.

Call or contact us online to speak with a lawyer.

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