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From Health Law Daily, April 20, 2018

Billing revocation upheld, doctor can’t be in two places at once

By Sheila Lynch-Afryl, J.D., M.A.

CMS properly revoked a medical practice’s Medicare enrollment because it repeatedly billed Medicare for services that its owner/operator could not have performed. The practice conceded, with a few exceptions, that the owner was out of the country and did not provide the services for which it billed Medicare (Clear Vue Laser Eye Center, Inc. v. CMS, Docket No. C-16-179, Decision No. CR5016, January 30, 2018).

In June 2015, the Medicare administrative contractor (MAC) advised the practice that its Medicare billing privileges were revoked pursuant to 42 C.F.R. sec. 424.535(a)(8) because it submitted multiple claims for the services of its owner and operator that could not have been rendered because she was out of the country at the time. CMS upheld the revocation and the practice appealed to the Departmental Appeals Board.

The evidence showed that over a period of six years, the practice billed Medicare for 142 services provided while the owner was out of the country. The practice contended that these were a result of billing errors, including incorrect dates of services and omitted modifiers. However, Medicare rules provide no exceptions accidental billing errors. Furthermore, while the practice claimed that it had substitute physicians while the owner was out of the country, most of the substitute physicians’ declarations said only that they "routinely" provided services for the owner’s patients without specifying the services provided.

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