An administrative law judge (“ALJ”) recently upheld the revocation of a Medicare Home Health Agency’s (“HHA”) billing privileges, based on the fact that the HHA did not properly notify CMS of a practice location change.
42 C.F.R. Section 424.516(e), requires certain health care providers to report changes to CMS within 90 days. Neither CMS nor the Medicare administrative contractor (“MAC”) received notification of the HHA’s address change within the required time frame.
The MAC conducted an unannounced site visit to the address on file for the HHA and determined that the location was vacant. As a result, the MAC informed the HHA that its billing privileges were revoked, retroactive to the date of the failed site visit.
The HHA sought reconsideration of the decision with the Center for Program Integrity who found that the new address was not in the Provider Enrollment, Chain, and Ownership System, and therefore the decision to revoke the billing privileges was justified.
The HHA availed itself of another reconsideration review and participated in a hearing before the ALJ. After the hearing, the ALJ determined that the HHA’s alleged notice attempts were insufficient to inform CMS of the change or beyond the 90-day notice window; and the obligation to be operational requires a provider to be operational at the specific location on file with CMS. Further, under 42 C.F.R. Section 405.800(b)(2), if the practice location is determined by CMS or its contractor not to be operational, the revocation is effective on the date that CMS or its contractor determined that the provider or supplier was no longer operational – in this case, the date of the site visit.
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The HHA had notified a state agency about its location change and claimed that it was open at a different location at the time of the site visit, but it did not submit the required change of address information to CMS, and that was sufficient to revoke the billing privileges.
The outcome of this case is a reminder to all health care providers of the undeniable responsibility to understand the requirements and obligations under Medicare, as well as the significant ramifications if they don’t.
If you have questions about this case or about your obligations under Medicare, please call Attorney Jillian Jagling at 401-824-5100 or email We welcome your comments, questions and suggestions.
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