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Leadership/Management

Legal Lesson of the Month: Keep Medicare in the Loop

G. Christopher Kelly

EMS can be full of interesting and tricky legal scenarios. While you can’t have an attorney ride with you, it behooves providers to have at least some familiarity with the principles, precedents, and major issues of EMS law. To that end EMS World is pleased to offer the EMS Legal Lesson of the Month.

These cases are presented by prominent attorneys in the EMS field. This month’s comes from G. Christopher Kelly, chief legal officer for EMS Consultants, LaGrange, Ga., and a member of EMS World's editorial advisory board. 

Filling out the CMS-855 form to enroll as a Medicare participant is probably one of the first things any healthcare organization does. However, Medicare enrollment is not a one-and-done type of process, or even a revalidate-every-five-years process. When you sign up, you create a contractual obligation to keep your enrollment up to date from that point on. Unfortunately I have seen failure to keep up with the required changes cause severe and irreparable consequences for ambulance service suppliers. Here are a few of the issues that require action and what Medicare expects from you on each one:

  • Ambulance license—Your state license must be current—any lapse in an active license may result in suspension from the Medicare program. The biggest problem here is that some states don’t get you an updated license until the last minute, and then the Medicare system takes up to 30 days to process it, often leading to a temporary suspension despite your best efforts. The best approach is to try to have your renewed license uploaded to your Medicare administrative contractor (MAC) at least a month in advance. While this type of temporary suspension can cause cash-flow problems, the rest of this list can lead to revocation, causing catastrophic consequences. 
  • Change in ownership—When your organization adds or removes an owner with more than a 5% interest in the business, you have 30 days to revise your Medicare enrollment. 
  • Adverse legal action—You must give notice within 30 days of any federal or state felonies of which the supplier or any owner or managing employee of the supplier is convicted that CMS may deem detrimental to the best interests of the Medicare program and its beneficiaries. Such offenses include felony crimes against persons, such as murder, rape, assault, and similar crimes for which the individual was convicted, including guilty pleas and adjudicated pretrial diversions; financial crimes, such as extortion, embezzlement, income tax evasion, and insurance fraud; and any felony that placed the Medicare program or its beneficiaries at immediate risk, such as a malpractice suit that resulted in a conviction of criminal neglect or misconduct.
  • Change in location—You must give notice of any new address within 30 days of operating at the new location. This may be the most frequent basis for enrollment problems because it is an error Medicare can easily catch by a piece of returned mail or random site visit. 

Other changes require notice within 90 days and include adding zip codes of operation, adding additional ambulances, and changes to your listed authorized officials.

Penalties

What happens if you fail to make the update within the required amount of time? Some failures can lead to overpayments; others can lead to complete revocation of your provider enrollment. Under the regulations Medicare should, in certain circumstances, give you notice and an opportunity to take corrective action on any failure it detects, but the MACs often skip that process and go straight to suspension or revocation, which is within their discretion. If you are revoked for any of the reasons above, it can be retroactive to the time you should have submitted the correction, creating a huge overpayment for the funds you’ve received in the interim. And of course Medicare funds from that point forward are cut off immediately, meaning no money for any Medicare patient transport. Also, these revocations normally state that you cannot re-enroll for a period of 2–5 years! 

While you have appeal rights, the chance of success is not good if you have in fact failed to provide the information in the required time frame. This makes Medicare enrollment a very important area of your business and perhaps one of the most hazardous areas for noncompliance. 

Make sure you know what your current Medicare enrollment says, and make sure you keep up with the required changes when they happen. Failure to do so can close the doors of even the best of ambulance service suppliers. 

G. Christopher Kelly is an attorney who focuses on federal laws and regulations as they relate to the healthcare providers and specifically the ambulance industry. Chris lectures and advises EMS service clients across the U.S. This article is not intended to be legal advice; for more information or specific questions, reach Chris at chriskelly@ems-ambulance.law.
 

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