Minor sanctions may now affect your Medicare eligibility

The CMS recently sent out the updated Medicare Physician Fee Schedule, and it could change everything. For starters, formerly benign Medical Board sanctions could now cost you your Medicare billing privileges.

As reported by Policy & Medicine, the changes all hinge on a single paragraph tucked deep into the 808-page document. This paragraph grants the CMS a new authority to revoke providers’ Medicare billing privileges. And it has already come under fire.

The stakes of a Medical Board hearing are higher than ever

There were already plenty of reasons to be concerned about standing before the Medical Board of California. This update adds another. It grants the CMS the ability to deny or revoke billing privileges to anyone who has:

“[…] been subject to prior action from a state oversight board, federal or state health care program, Independent Review Organization (IRO) determination(s), or any other equivalent governmental body or program that oversees, regulates, or administers the provision of health care with underlying facts reflecting improper physician or other eligible professional conduct that led to patient harm.”

The CMS says it added the language because it was concerned that some state boards were handing out small punishments for big offenses. It also claims that it would not automatically act against providers who have received only modest sanctions. Instead, the CMS says it will revoke privileges only after considering:

• The nature of the patient harm
• The provider’s conduct
• The number of disciplinary actions against the provider
• The existing disciplinary findings

But these reassurances aren’t enough for everyone. Groups such as the American College of Surgeons and American Medical Association have railed against the change as a troubling overreach. They also criticized the CMS for inserting the paragraph into a section about opioid treatment. That made it look as though it was contained to the opioid issue, even though it wasn’t.

Why take chances?

As Policy & Medicine noted, the CMS responded to some of these concerns with three examples of how it might choose whether to revoke billing privileges. The examples suggest the CMS would look closely at the nature of patient harm and the actions of state boards. But a recent article in JD Supra noted that the CMS has historically revoked plenty of billing privileges for minor noncompliance issues.

The result is that providers will need—more than ever—to present themselves well before the Medical Board of California. If you need to face the Medical Board, it may not be enough to just defend your license. You may need to think about your billing privileges, too.