Physicians and other providers and suppliers who are enrolled in the Medicare program should be aware that federal regulations require them to report to the Medicare program all “Final Adverse Actions/Convictions” within 30 days after the reportable event. These notifications should be made to the Medicare Part B carrier.
Reportable Final Adverse Actions/Convictions include the following:
- Any revocation or suspension of a license to provide healthcare by any state licensing authority. This includes the surrender of a license while a formal disciplinary proceeding was pending before a state licensing authority.
- Any revocation or suspension of accreditation (for accredited providers such as laboratories).
- Any suspension or exclusion from participation in, or any sanction imposed by, a federal or state healthcare program, or any debarment from participation in any federal procurement or non-procurement program.
- Any current Medicare payment suspension under any Medicare billing number.
- Any Medicare revocation of any Medicare billing number.
- Conviction within the ten years preceding enrollment or revalidation of enrollment of a federal or state offense that CMS has determined to be detrimental to the best interest of the program and its beneficiaries; financial crimes such as extortion and embezzlement; and any felony that places beneficiaries at immediate risk, such as a malpractice risk that results in a conviction of criminal neglect or misconduct.
- Any misdemeanor conviction, under federal or state law, related to the delivery of an item or service under Medicare or a state health care program, or the abuse or neglect of a patient in connection with the delivery of any healthcare item or service.
- Any misdemeanor conviction, under federal or state law, related to theft, fraud, embezzlement, breach of fiduciary duty, or other financial misconduct in connection with the delivery of a healthcare item or service.
- Any felony or misdemeanor conviction, under federal or state law, relating to interference or obstruction of any investigation into a criminal offense.
- Any felony or misdemeanor conviction, under federal or state law, relating to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance.
Note that convictions also include any plea of guilty.
Reporting of any such Final Adverse Actions/Convictions within the 30-day period is critical. Penalties for failure to report include recoupment of any amounts paid by the Medicare program for services rendered by the provider or supplier during the time period for which no reporting was made, as well as revocation of the Medicare participation status of such provider or supplier, with a one-year bar to reapplication for participation in the Medicare program. CMS, as part of its program integrity measures, is increasing its review of disciplinary actions by state licensing boards, conviction records, etc. in an attempt to identify providers or suppliers who may have failed to make the required reporting.
Providers should also be aware that if they chose not to contest certain state license actions (for example, potentially adverse actions regarding out of state licenses that are no longer needed by the provider), the failure to contest the action could be deemed a revocation or suspension, thus triggering the reporting requirement.
For more information, please contact:
Jane Pine Wood
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