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By: Pam Felkins Colbert, The van Halem Group Hang on to your hat and your billing number. It’s gonna be a bumpy ride! As we shared with you back in 2014, the Centers for Medicare and Medicaid Services (CMS) issued a new Final Rule in December 2013 announcing that CMS, under the authority of the Affordable Care Act (ACA), can and will revoke or deny enrollment and billing privileges of providers/suppliers who have a “pattern and practice” of submitting improper claims that do not comply with Medicare regulations and pose a program integrity risk to Medicare. That Final Rule had become part of federal law and is now included in CMS’ online Program Integrity Manual - Medicare Enrollment, Chapter 15.27.2 (effective 11/02/15), which lists 14 “Revocation Reasons.” Reason #8: Abuse of Billing Privileges is where CMS gives a “hint” of how it determines “pattern and practice” of submitting claims that fail to meet Medicare requirements that may result in your revocation of billing privileges. These factors include:

1. Percentage of claims submitted that were denied
2. Reason(s) for claim denials
3. Provider/Supplier history of final adverse actions and nature of such actions
4. Length of time over which the pattern has continued
5. How long the provider/supplier has been enrolled in Medicare
6. Any other relevant information regarding the provider/supplier specific circumstances that CMS deems relevant

See chapter 15 of the Medicare Program Integrity Manual. CMS’ Zone Program Integrity Contractors (ZPICs) have also been authorized, as part of its investigations, to recommend revocation of billing privileges. The ZPIC sends its investigation file to the CMS Provider Enrollment Operations Group (now part of CMS’ program integrity functions) to recommend revoking a provider or supplier’s billing privileges. The recommendation may be accepted or sent back for further investigation. As the ZPIC contracts have come up for re-bid to become Unified Program Integrity Contractors (UPICs), we see much more aggressive investigations and audits, possibly in hopes to support their bids for the UPICs. ZPIC investigations now often include suspension of payments, 100 percent prepay reviews and a closing paragraph, which states: “Per 42 CFR Section 424.535(a)(8), CMS has the authority to revoke a currently enrolled provider or supplier’s Medicare billing privileges and corresponding provider agreement based on a pattern and practice of submitting claims that fail to meet Medicare requirements. Should you continue to fail to meet these requirements as described above, your billing privileges may be revoked on this basis or any of the bases articulated in 42 CFR Section 424.535(a).“ It is more important than ever to make certain your claims are complete and accurate and have appropriate supporting documentation. If not, you could be deemed as submitting “improper claims that fail to meet Medicare requirements” and “pose a program integrity risk to the Medicare.” If you have been audited in the past, had overpayments taken, educated on the same errors and advised as to why your claims were denied, make certain you DO NOT continue to submit claims with the same errors; this will be scrutinized under the “pattern and practice” elements, and CMS (or its contractors) can and may revoke your billing privileges and corresponding provider agreement. Be prepared. Be proactive. Prevent audits and overpayments. Protect your billing privileges and provider/supplier agreement. Are you going to Heartland Conference? If so, attend my session, “How to Navigate the Turbulent Waters of Health Care in 2016.”