CMS Expands Medicare's Authority to Deny and Terminate Physicians and Other Providers-Why This Matters

Thursday, December 11, 2014
By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law

Stop me if you've heard this one before: the Centers for Medicare and Medicaid Services (CMS) recently increased Medicare's authority over physicians and other health care providers. On December 3, 2014, CMS released these new anti-fraud measures. This matters to physicians and health care providers because Medicare now maintains the authority to deny or revoke the enrollment of medical providers for many reasons.

Click here to read the new rules

These new rules stem from provisions of the Patient Protection and Affordable Care Act.

A Summary of the New Rules.

According to The Wall Street Journal, the current "pay-and-chase" reimbursement model that Medicare uses led to an estimated $45.8 billion of improper Medicare payments in the last fiscal year. Medicare is often slow to kick out bad actors because it first must undertake lengthy audits and claims reviews. The federal program now has the authority to quickly ban providers acting improperly. Under the new rules, Medicare can now:

- Deny the enrollment of physicians and other health care providers, suppliers and owners affiliated with an entity that has unpaid Medicare debt, existing overpayment or other forms of financial obligation. What this means, in part, is if you are one of the owners or managers of a group or entity with an unpaid Medicare debt, you can be terminated or barred from the Medicare program;

- Deny the enrollment or revoke the billing privileges of providers or suppliers who have a managing employee that has been convicted of certain felonies deemed detrimental to Medicare beneficiaries; and

- Revoke the billing privileges of physicians and providers and suppliers who have a pattern of inappropriate billing.

To read the entire article from The Wall Street Journal, click here.

What Happens If You Make Innocent Errors?

Health care providers now fear this new authority combined with increasingly complex billing requirements will lead to the exclusion of doctors who make innocent billing mistakes. However, CMS says not to worry. Medicare will only use its new authority in clear cases, and when providers are warned but don't change their behavior.

As these new rules come into play, Medicare providers need to be ever vigilant in their billing compliance. With tougher billing requirements, it's important to ensure everyone billing Medicare is coding correctly. Consider hiring a professional to perform a pre-audit. Also, you may want to send your practice to continuing education classes to keep up to date on new regulations.

These new rules also make it imperative to perform employee background checks. We suggest these checks be conducted when hiring a new employee, and sporadically to verify current employees maintain clean backgrounds.

Few physicians and health care providers understand the significance of exclusion from Medicare. You can read about the seriousness of this matter by clicking here. Fight any action commenced to suspend or terminate your participation in the Medicare Program or to exclude you. Having the knowledgeable and competent help of a health law attorney will be invaluable. If you find yourself the target of an audit or fighting exclusion, perform your due diligence and find an advocate to assist in your fight.


What do you think of the new authority given to Medicare? How will these rules impact your practice? Please leave any thoughtful comments below.

Don't Wait Until It's Too Late; Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

If you receive any notice related to any audit, overpayment or action to terminate you or your company, take immediate action. The attorneys of The Health Law Firm represent healthcare providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

We also represent physicians, medical groups, pharmacies. health facilities and therapists in notices of termination of Medicare billing privileges, corrective action plans (CAPs), OIG exclusion hearings, Medicaid hearings and applications for removal from the List of Excluded Individuals and Entities (LEIE).

For more information please visit our website at or call (407) 331-6620 or (850) 439-1001.


Adamy, Janet. "New Medicare Rules Aim to Reduce Abuse." The Wall Street Journal. (December 4, 2014). From:

Dickson, Virgil. "Docs Fret Medicare's Hunt for 'Bad Actors' Will Snare Good Guys." Modern Healthcare. (December 3, 2014). From:

About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

Tag Words: Medicare, Medicare rules for physicians, new Medicare rules, Medicare rules for health care providers, Centers for Medicare and Medicaid Services, CMS, anti-fraud rules, Medicare fraud, Medicare abuse, Medicare providers, Medicare audits, Medicare defense, defense attorney, defense lawyer, Medicare billing privileges, Medicare exclusion, the Medicare program, health law, The Health Law Firm

"The Health Law Firm" is a registered fictitious business name of George F. Indest III, P.A. - The Health Law Firm, a Florida professional service corporation, since 1999.
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George F. Indest III 12/11/2014

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