Feder al Registe r /Vo l. 73, No .
125 /Fri da y, June 27 , 2008/Rules
successfull y overturned at a higher level
ofappeal .
Response: Section 405.874(d)(3) states
a provider or supplier's billing
privileges will be reinsta ted back to the
date that their revocation became
effective if it was reversed at a higher
level of appeal.
Comment: Several commenters
recommended that we clarify that the
period of provider or supplier
ineligibility be linked to the date on
which the supplier had provided a
service to a beneficiary and not the date
that a claim would be received or
processed by a carrier.
Response: We are clarifying that this
is our intent. Revocation actions
concerning provider and supplier
ineligibility are based upon the date on
which the provider or supp lier had
furnished a service to a beneficiary and
not the date that a claim was received
or processed by a carrier or MAC.
For example, if a provider submits a
claim for services provided on June 22,
2007, and the beneficiary dies on June
23, 2007, but the claim for the June 22,
2007 services was not received until
August 1, 2007, if any action is taken
regarding this claim , it would be wi th
regard to the June 22, 2007 date.
Comment: One commenter suggested
that there are several instances ,11here
the date of service being billed could
actually be the day after the date of
death and that an honest billing of the
service could be perceived as fraud , and
therefore cause a provider or supp lier to
be incorrectl y revoked.
Response: We understand that there
are certain situations when the date of
service may legitimately be the day after
the date of death of the beneficiary .
According!y, Medicare contra ctors and
CMS will review the specific details
associated with each claim before taking
any revocation action.
Comment: We received several
comments regarding implementation of
the proposed changes to be set forth at
424.535(a)(8) which allows Medicaxe
contractors to revoke Medicare billing
privileges when a provider or supplier
submi ts a claim or claims for services
that could not have been furnished to a
beneficiar y, where the commenter
believed there was not enough guidance
given to the contractors to filter these
claims which could cause overburdened
contractors to implement this policy too
widely.
Response: CMS, not a Medicare
contractor, will make the determination
for revocation under the author ity at
424.535(a)(8). We will direct
contractors to use this basis of
revocation after identifying providers or
suppliers that have these billing issues.
and Regulations 364 55
We have found numero us examples of Response : As outlined in 424.510,
situations where a ph ysician claims to the curren t eruo llment application
have furnished a service to a beneficiary procedures allow providers and
more than a month after their recorded supp liers a clear means to complete and
death , or when the provider or supplier submi t eruollment applications with the
was out of State when the supposed necessary documen tation to participate
services had been furnished . In these in the Medicare program. Prospective
instances , the provider has billed the providers or suppliers are responsib le
Medicare program for services which for obtaining the necessary
\i\tm:1u ul p1uvi<ltH.la.u<lh a.s .suLu.tiLLt,<l documentation that demonstra tes that
Medicare claims for service to a they meet the program requirements for
beneficiary who could not have received their provider or supplier type. If a
the service which was billed. This provider or supplier cannot supp ly the
revocation authority is not intend ed to necessary documen tation at the time of
be used for isolated occurrences or filing or in response to a contrac tor
accidental billing errors. Rather, this request , then the contrac tor is required
basis for revocation is directed at to reject their application and the
providers and suppliers who are prospective provider or supplier must
engaging in a pattern of improper begin the eruollmen t process anew.
billing . Finally, a prospective provider or
In making a revocation determination supp lier may withdraw their Medicare
under 424.535(a)(8), we will make the eruo llment application at any time by
revocation determination based upon informing the designated contractor in
information presented by a Medicaxe writing of the with drawal of the
contractor , a CMS Regional Office, or application . A withdrawal request must
one of our Program Integrity field be made by the applica nt or the
offices. We believe that it is both Authorized Official as defined in
appropriate and necessary that we have 424.502 and in the Medicare
the ability to revoke billing privileges eruo llment application (CMS-855).
when services could not have been
Unlike the claims appeals process
furnished by a provider or supplier. We where minor errors and omissions can
recognize the impact that this
revocation has, and a revocation will be resolved though the reopening
process in an effective and efficient
not be issued unless sufficient evidence manner , the issues involved in Provider
demonstrates abusive billing patterns.
Enrollment denials and revocations do
According ly, we will no t revo1ce billing
privileges under 424.535(al(8) unless not readily lend themselves to the
reopening process. According!y, we
there are multiple instances , at least have not adopted a reopening procedure
three , where abusive billing practices
have taken place. Furthermore , in this final rule.
providers and suppliers may appea l a Comment: One commenter
contractor revocation using the process recommended that we revise our 2002
outlined in part 498 if they believe that "Do Not Forward" policy because of the
they were undu ly revoked . In change in processing timeframes for
conclus ion, we believe that providers eruo llment applications .
and supp liers are responsib le for the Response : We believe this issue is
claims they submit or the claims outside the scope of the proposed rule
submitted on their behalf . We believe and can not be addressed in this final
that it is essential that providers and rule.
suppli ers take the necessary steps to Comment: One commenter
ensure they are billing appropr iate!y for recommended that if we make a change
services furnished to Medicare in the Medicare eruollmen t application
beneficiaries. that we use the processing guidelines in
Comment : Several commenters effect at the time of the postmark date
believed that contractors would be so that the application will be treated as
issuing revocations based upon the submitted prior to the implementation
submission of claims for services that date.
could not be delivered. Response : If we make a change in the
Respons e: As stated above, we will Medicare enrollment application in the
instruct Medicare contractors to issue a future, we will establish a transition
revocation under 424.535(a)(8). period between the use of the prior
Comment : One commenter suggested version of the application and the new
several procedural changes regaiding version of the application .
the process ing of eruo llment Comment: One commenter stated that
applica tions; such as, with drawing an electronic funds transfer (EFT) should
app lication and reopening a closed be developed in concert with the CMS--
enrollment decision, be included in this 855 transaction standard to ensure that
regulation as opposed to our original there is a clear connection between the
procedUial proposals . two files.