HHS DAB Upholds Revocation of Clinic’s Medicare Provider Number


On February 20, 2014, the US Department of Health and Human Services, Departmental Appeals Board upheld CMS’ revocation of the Medicare provider number of a clinic/group practice.

In Advanced Care Medical Center v CMS (Docket No. C-13-1383/Decision No. CR3124), the DAB, Civil Remedies Division upheld CMS’ revocation of Advanced Care’s Medicare provider number.

The matter began with an investigation by the Office of the Inspector General which revealed that Advanced Care entered into a contract with a doctor, allowing him to bill for services under it’s billing number in exchange for a set reimbursement, and the doctor submitted bills under Petitioner’s billing number.  As a result, Wisconsin Physicians Service (WPS), the Medicare contractor, notified Petitioner that it was revoking its billing privileges pursuant to 42 C.F.R.§ 424.535(a)(7) for a period of two years, effective July 28, 2013, for misuse of its billing number.

The facts were uncontroverted  and as a result the DAB was compelled to uphold the revocation of Medicare enrollment because Advanced Care allowed an individual to improperly use its billing number. 

Advanced Care had submitted a request for equitable relief asking for leniency and claiming it made an innocent mistake which will never happen again. Once it realized its mistake, it immediately cancelled the contract with the doctor and did not do anymore billing, and its bank statements from May through October 2013 show it did not receive funds from Medicare.

However, the ALJ opined that he had no authority to provide equitable relief, citing US Ultrasound, DAB No. 2302, at 8 (2010) (“[n]either the ALJ nor the Board is authorized to provide equitable relief by reimbursing or enrolling a supplier who does not meet statutory or regulatory requirements.”). 

The moral of the story is that Medicare providers, particularly small providers, need to pay close attention to their compliance, enrollment and participation obligations in the program. Loose arrangements with providers or lending out billing numbers create serious compliance issues and providers need to effectively scrutinize and talk to their compliance and legal advisors to be sure that arrangements are in compliance. What may seem like a small transgression, can and does have disastrous consequences as it did in this matter.

You can find a copy of the DAB Decision here  —>   Docket No. C-13-1383/Decision No. CR3124

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DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

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