Anyone who reports a change of information or ownership is asked to report final adverse legal actions. Final adverse legal actions that are required to be reported by providers, suppliers and owners within 30 days include:
- Suspension or revocation of a license to provide health care
- Revocation or suspension by an accreditation organization
- Federal or State felony conviction that is detrimental to Medicare or its beneficiaries
- Misdemeanor in connection with the delivery of health care related to:
- The delivery of an item or services under Medicare or a state health care program
- Patient abuse or neglect
- Theft, fraud, embezzlement, breach of fiduciary duty or other financial misconduct
- Misdemeanor or felony convictions related to:
- unlawful manufacturing, distribution, prescribing or dispensing of a controlled substance
- Interference or obstruction with an investigation into any criminal offense that is grounds for exclusion
- Exclusion or debarment from participation in a Federal or State health care program
- Medicare imposed revocation of any Medicare billing privileges or current suspension of Medicare billing privileges
“Suspension and revocation” includes surrender of a license to practice health care during formal disciplinary proceedings.
“Conviction” includes a plea of guilty or nolo contendere, or a judgment of conviction against an individual or entity, regardless of expungement or pending appeals or motions.
“Detrimental to Medicare and its beneficiaries” has been interrupted by some MACs to include all felony convictions, not just felonies enumerated in 42 CFR § 424.535(3)(ii). Therefore, contact our attorneys for assistance in determining whether the felony conviction is reportable as an adverse legal action.
Our health care lawyers are highly experienced in representing providers with enrollment issues. If our attorneys determine that the felony conviction is reportable, our attorneys will help you prepare an explanation to your MAC and represent you during any hearings or appeals.
Adverse legal actions affect enrollment eligibility and are likely to result in a further investigation by MAC. If MAC determines that a provider, supplier or organization no longer meets the enrollment requirements, they will seek revocation of billing privileges. Providers, suppliers and owners have the right to appeal a revocation determination.
For more information about revocations, see Medicare Revocations.