Reversing Revocation Based on Owner or Employee’s Wrongdoing
Revocations for adverse activity of an owner, managing employee, an authorized or delegated official or other health care personnel of the provider or supplier may be reversed if the provider terminates its relationship with the wrongdoer. Providers must submit proof of termination within 30 days to their contractor. Contractors have the authority to rescind the revocation.
Corrective Action Plans (CAP)
If the denial or revocation is based in whole or part on deficiencies (§ 424.535(a)(1)) that can be corrected, providers and suppliers may submit a corrective action plan showing they are in compliance with Medicare requirements. CAPs must be submitted within 30 days of the denial or revocation and must comply with certain requirements. The contractor must deny or approve the CAP within 60 days of receipt. Approval of the CAP rescinds the denial or revocation. Contractors may adjust the billing effective date. Submitting a CAP does not preserve appellate rights or toll the appeal deadline. Therefore, it is critical that CAPs comply with the requirements and contain sufficient evidence of compliance. Our attorneys can help determine whether a CAP is the best option for you; if so, we will prepare one and ensure your appeal rights are preserved.
Providers and suppliers can also submit a reconsideration request to their contractor. Reconsideration requests must be submitted within 60 days of receipt of the notice of denial or revocation. Failure to timely submit a reconsideration request is a waiver of all further appeal rights. A hearing officer not involved in the initial determination will make a determination upholding or overturning the revocation or denial within 90 days of the receipt of the request. Evidence may be submitted for consideration prior to the reconsideration determination. Future appellate proceedings may reject any evidence that was not submitted for reconsideration. Therefore, you should obtain assistance from an experienced attorney to prepare your reconsideration request.
Administrative Hearing (ALJ)
If providers and suppliers are unsuccessful with the reconsideration, they may appeal the decision to an administrative law judge (ALJ) with HHS. A request for an administrative hearing must be properly filed with 60 days of receipt of the reconsideration decision. At this point, the case will be prepared by an experienced CMS attorney and will be subject to administrative procedures. Therefore, it is strongly advised that providers and suppliers retain an attorney to handle the appeal. An attorney will be able to prepare the case (collect evidence, cross-examine witnesses, file briefs, etc.), attempt settlement and represent your interests during the hearing. Many cases are settled prior to the hearing.
Departmental Appeals Board (DAB)
Both CMS and providers and suppliers can appeal an ALJ decision to the DAB. A request for a DAB review must be filed within 60 days after the ALJ renders its decision. As with ALJ hearings, DAB proceedings are formal and subject to specific procedures. The DAB has authority to deny review of the case. Therefore, providers and suppliers should retain an attorney who is experienced with DAB proceedings to prepare the request.
A provider or supplier may seek judicial review if they are unsatisfied with the DAB’s decision by filing a civil action in District court within 60 days.