Medicare enrollment can be denied due to outstanding overpayments

March 13, 2018

Blog Post

The Centers for Medicare and Medicaid Services (CMS) recently issued a notice regarding its intent to start denying provider enrollment or change of ownership applications where there is an outstanding Medicare overpayment owed by a provider, supplier or owner.

CMS has had this authority for years pursuant to existing regulations but this latest change request establishes CMS’ intent that it may start utilizing that authority. Owner is defined as any individual or entity that has any partnership interest in, or has 5 percent or more direct or indirect ownership of, a provider or supplier. A supplier includes physicians, non-physician practitioners, physician groups and non-physician practitioner groups. The current minimum overpayment for purposes of this notice is $1,500. This $1,500 will include the principal overpayment amount and accrued interest.

Some exclusions from denials under this notice:

Overpayments that are currently being appealed.
Overpayments that are part of an approved repayment schedule.
Instances where the provider is bankrupt.
Instances where the provider voluntarily refunded the overpayment
Where there has been less than 60 days from the first demand of return of the overpayment. This can be particularly relevant in situations where an owner moves from one provider to another where the former provider had an overpayment debt or in acquisitions of or creation of new providers who are seeking to enroll in Medicare.

If you have any questions regarding this matter please contact the attorneys below.

Over the past 24 months, the U.S. Department of Health and Human Services Office for Civil Rights has brought notable enforcement efforts against several non-profit covered entities and business associates, resulting in instances of six and seven-figure penalties against providers across the county for incidents involving breaches of protected health information.

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On November 1, 2024, the Centers for Medicare & Medicaid Services issued the Medicare Physician Fee Schedule 2025 final rule, which establishes new advanced primary care management billing codes that will expand opportunities for physician practices, federally qualified health centers, rural health clinics and other health care providers to get paid for services provided by clinical staff under the direction of a physician, nurse practitioner or physician assistant beginning January 1, 2025.

Medicare enrollment can be denied due to outstanding overpayments

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