Can Medicare revoke my provider enrollment?

Yes. CMS can revoke Medicare billing privileges for various reasons, including felony convictions, loss of state licensure, failure to comply with enrollment requirements, false statements on enrollment applications, abuse of billing privileges, and failure to report changes in enrollment information. Revocation bars the provider from re-enrolling for one to ten years depending on the reason. Providers have the right to appeal revocations through CMS reconsideration and then to an ALJ hearing.

What is the difference between a Medicare coverage denial and a payment dispute?

A coverage denial means Medicare has determined that the service is not covered under the program, either because it does not meet the definition of a covered benefit or because it was not medically necessary. A payment dispute involves a covered service where the amount of payment is contested. Both types of disputes can be appealed through the Medicare administrative appeals process, but the legal and medical arguments differ significantly.

How does Medicaid eligibility work, and can it be appealed?

Medicaid eligibility is determined by state Medicaid agencies based on income, household size, disability status, and other factors established by federal law and the states Medicaid plan. Applicants who are denied coverage or whose benefits are reduced or terminated have the right to a fair hearing before a state hearing officer. The Affordable Care Act expanded Medicaid eligibility in states that chose to adopt the expansion, covering adults with incomes up to 138% of the federal poverty level.

What is the 60-day rule for overpayment reporting?

Section 6402 of the Affordable Care Act requires healthcare providers to report and return identified overpayments to Medicare or Medicaid within 60 days of the date the overpayment was identified. Failure to comply can result in liability under the False Claims Act, which carries penalties of up to three times the overpayment amount plus per-claim penalties. The definition of when an overpayment is identified and the scope of the obligation to investigate potential overpayments are actively litigated issues.

Can I participate in both Medicare and Medicaid simultaneously?

Yes. Healthcare providers can and often do participate in both programs. However, each program has its own enrollment requirements, billing rules, and compliance obligations. Providers must maintain separate compliance with both sets of requirements. For patients who are dually eligible for both Medicare and Medicaid, Medicare generally serves as the primary payer, with Medicaid covering remaining costs including Medicare premiums, deductibles, and copayments.

Medicare & Medicaid Attorneys

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~66.7 million

Total Medicare Enrollment (2023)

Source: CMS Medicare Enrollment Dashboard

~92 million

Total Medicaid/CHIP Enrollment (2023)

Source: CMS Medicaid and CHIP Enrollment Data

$944 billion

Total Medicare Spending (FY 2023)

Source: CMS National Health Expenditure Data

$2.1 billion in false claims

Medicare Fraud Strike Force Charges (2023)

Source: DOJ Health Care Fraud Unit

About Medicare & Medicaid

Medicare and Medicaid are the two largest government-funded healthcare programs in the United States, collectively providing coverage to more than 150 million Americans. Medicare, established in 1965 under Title XVIII of the Social Security Act, is a federal program primarily serving individuals aged 65 and older, certain younger people with disabilities, and those with end-stage renal disease. It consists of Part A (hospital insurance), Part B (medical insurance), Part C (Medicare Advantage plans), and Part D (prescription drug coverage). Medicaid, established under Title XIX of the Social Security Act, is a joint federal-state program providing healthcare coverage to low-income individuals and families, with eligibility and benefits varying significantly from state to state.

Medicare and Medicaid law encompasses a vast regulatory framework governing provider enrollment and participation, coverage determinations, billing and reimbursement, fraud and abuse enforcement, administrative appeals, and regulatory compliance. The Centers for Medicare & Medicaid Services (CMS) administers both programs and issues thousands of pages of regulations, manual provisions, transmittals, and guidance documents that healthcare providers must navigate. State Medicaid agencies administer Medicaid programs within their borders, subject to federal requirements and their approved state plans.

Legal issues in Medicare and Medicaid touch virtually every healthcare provider and supplier in the country. Common legal matters include disputes over coverage and payment, provider enrollment challenges, audits by Medicare Administrative Contractors and Recovery Audit Contractors, overpayment determinations, fraud investigations by the OIG and state Medicaid fraud control units, and compliance with conditions of participation. The financial stakes are enormous, as Medicare alone processes over one billion claims annually with total expenditures exceeding $900 billion per year.

Why You Need a Medicare & Medicaid Attorney

Medicare and Medicaid represent the financial backbone of the American healthcare system. For many healthcare providers, these programs account for the majority of their revenue. Hospitals, nursing homes, home health agencies, and physicians who serve elderly, disabled, or low-income populations are particularly dependent on government reimbursement. Losing the ability to participate in these programs through revocation of enrollment, exclusion for fraud, or termination for failure to meet conditions of participation can be financially catastrophic. Even disputes over payment rates, coverage determinations, or overpayment assessments can involve millions of dollars and threaten the viability of healthcare organizations. The administrative appeals process for Medicare and Medicaid disputes is complex and time-sensitive, with strict deadlines that must be met to preserve appeal rights. Providers need attorneys who understand both the legal framework and the practical realities of healthcare billing and operations.

Common Medicare & Medicaid Cases

Medicare and Medicaid Fraud Defense

Defense against allegations of billing fraud, including False Claims Act qui tam lawsuits, OIG investigations, and criminal prosecution for submitting false claims to government healthcare programs.

Overpayment and Recoupment Disputes

Challenging determinations that a provider has received overpayments from Medicare or Medicaid, including statistical extrapolation methodologies used to project overpayment amounts from sample audit findings to the entire claims universe.

Provider Enrollment Issues

Assisting with initial enrollment in Medicare and Medicaid, responding to revalidation requests, appealing denials of enrollment applications, and challenging revocations of billing privileges.

Coverage and Reimbursement Disputes

Challenging coverage denials, payment rate determinations, and classification decisions that affect how services are reimbursed. These disputes often involve complex questions of medical necessity and CMS coverage policies.

RAC and MAC Audits

Responding to audits conducted by Recovery Audit Contractors and Medicare Administrative Contractors, which review claims for overpayments, underpayments, and compliance with billing requirements.

Conditions of Participation Compliance

Addressing survey deficiencies and enforcement actions related to Medicare and Medicaid conditions of participation, which set quality and safety standards for hospitals, nursing facilities, and other institutional providers.

Medicaid Managed Care Disputes

Disputes between healthcare providers and Medicaid managed care organizations regarding payment rates, prior authorization denials, network adequacy, and contract terms.

Typical Medicare & Medicaid Case Timeline

Initial Determination or Audit Finding

1-6 months

Medicare or Medicaid issues a coverage denial, overpayment determination, enrollment revocation, or audit finding. Providers typically have 120 days to file a redetermination request for Medicare claims disputes.

First Level Appeal (Redetermination/Reconsideration)

60-120 days

The first level of appeal is reviewed by the Medicare Administrative Contractor or Qualified Independent Contractor. This paper-based review offers an early opportunity to present supporting documentation.

ALJ Hearing (Second Level)

6-18 months

Cases meeting the minimum amount in controversy can request a hearing before an Administrative Law Judge at the Office of Medicare Hearings and Appeals. This is typically the first opportunity for a live hearing.

Medicare Appeals Council Review

6-12 months

The Medicare Appeals Council reviews ALJ decisions and can affirm, reverse, or remand. This is the final level of administrative review before federal court.

Federal District Court

1-3 years

Appeals of Medicare Appeals Council decisions meeting the amount in controversy threshold can be filed in federal district court. Complex legal and constitutional issues may be raised at this level.

Know Your Rights

Providers have the right to appeal virtually every adverse Medicare and Medicaid determination through a multi-level administrative appeals process.
Medicare providers have the right to challenge overpayment extrapolation methodologies, including the statistical sampling approach, the error determinations, and the extrapolation calculations.
Providers have the right to continue receiving Medicare payments during certain appeal stages, subject to specific conditions and timelines for filing appeals.
Providers facing enrollment revocation have the right to a reconsideration and, if unsuccessful, to a hearing before an administrative law judge.
Medicaid providers have due process rights before their participation can be terminated, including notice and the opportunity to be heard.
Providers have the right to request an extended repayment schedule for overpayment assessments and to request hardship exceptions in certain circumstances.

What to Look for in a Medicare & Medicaid Attorney

Medicare and Medicaid law is highly specialized, and you should look for an attorney with deep experience in federal healthcare program regulations and the administrative appeals process. The ideal attorney will have experience before the Medicare appeals system, including Administrative Law Judges at the Office of Medicare Hearings and Appeals, the Medicare Appeals Council, and federal district court. They should understand CMS coverage policies, Medicare billing manuals, and the Local and National Coverage Determination processes. For fraud defense, look for an attorney experienced with False Claims Act litigation, OIG investigations, and CMS enforcement actions. Knowledge of statistical sampling and extrapolation methodologies is essential for overpayment disputes. For Medicaid matters, the attorney should be familiar with the specific state Medicaid program and agency practices involved, as Medicaid requirements vary significantly between states.

Questions to Ask Your Medicare & Medicaid Attorney

1What is the basis for the overpayment determination, and was the statistical sampling methodology used compliant with CMS requirements?
2What are the deadlines for each level of the appeals process, and what happens to our payment if we miss a deadline?
3Is there a basis to challenge the Medicare Administrative Contractors sampling frame, sample size, or extrapolation methodology?
4Should we request a stay of recoupment during the appeals process, and what are the requirements for obtaining one?
5Are there any applicable CMS manual provisions, Local Coverage Determinations, or National Coverage Determinations that support our position?
6What are the implications of this dispute for our ongoing participation in Medicare and Medicaid, and are there any parallel fraud or abuse concerns?
7Can we negotiate a settlement of the overpayment at a reduced amount, and what are the advantages and risks of settlement versus pursuing a full appeal?

Understanding Medicare & Medicaid Legal Costs

Medicare and Medicaid legal work is billed at hourly rates typically ranging from $350 to $700 per hour. Routine appeals of individual claims may cost $5,000 to $25,000. Complex overpayment disputes involving statistical extrapolation can cost $50,000 to $300,000 or more in legal fees, plus the cost of statistical experts. Provider enrollment matters typically cost $5,000 to $30,000. Fraud defense cases can cost hundreds of thousands to millions of dollars depending on the complexity and the government agencies involved. Some attorneys offer contingency or hybrid fee arrangements for overpayment appeals where the amounts in dispute are substantial. Given that overpayment demands can reach millions of dollars, the cost of legal representation is often a fraction of the amount at stake.

Key Legal Terms

Video Resources

These videos are provided for informational purposes only. The attorneys and organizations featured are not affiliated with or endorsed by Northwind Law.

Medicare Explained: Benefits, Coverage, and Costs

AARP

How Medicaid Works

Kaiser Family Foundation

Understanding Medicare Parts A, B, C, and D

Centers for Medicare & Medicaid Services

Frequently Asked Questions About Medicare & Medicaid

Do not ignore the demand, as failure to respond can result in recoupment from future payments. Review the demand carefully, including the methodology used to calculate the overpayment. Consult with an attorney experienced in Medicare appeals before responding. You have 40 days to request a redetermination, and filing a timely appeal at the right stage can stop or delay recoupment of the disputed amount. If statistical extrapolation was used, there may be grounds to challenge the sampling methodology.

Citations & Sources

[1]
Total Medicare enrollment reached approximately 66.7 million beneficiaries in 2023, including 60.3 million aged 65 and older and 6.4 million younger individuals with disabilities. — CMS Medicare Enrollment Dashboard, 2023
[2]
Medicare spending reached $944 billion in fiscal year 2023, representing approximately 21% of total national health expenditures and 3.5% of gross domestic product. — CMS Office of the Actuary, National Health Expenditure Data
[3]
The Medicare appeals backlog at the Office of Medicare Hearings and Appeals has exceeded 500,000 pending appeals in prior years, contributing to significant delays in the adjudication process. — HHS Office of Medicare Hearings and Appeals
[4]
The 60-day overpayment reporting rule under Section 6402 of the Affordable Care Act requires providers to report and return identified overpayments within 60 days or face potential False Claims Act liability. — 42 U.S.C. § 1320a-7k(d)
[5]
Medicaid enrollment surged to approximately 92 million individuals in 2023, though enrollment began declining as states resumed eligibility redeterminations following the end of the COVID-19 continuous enrollment requirement. — CMS Medicaid Enrollment Data Highlights

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