CMS looking for ways to boot providers who don’t correct repeated billing problems

by  Codapedia
December 2nd, 2015

By: Scott Kraft (Jan/30/2014) 

Providers with a history of making the same mistakes over and over again may find themselves on the outside of the Medicare program looking in, if CMS has its way. The agency has formalized a policy to use existing regulations to identify these providers and be able to issue civil monetary penalties against them or even exclude them from the Medicare program.

Keep in mind, these are not providers committing fraud – Medicare policy already allows those providers to face fines, exclusion of even criminal penalties.

These are what CMS refers to as “recalcitrant provider” – those who, despite repeated provider education and prepayment review, continue to make the same mistakes. In explaining its rationale for seeking to fine or exclude these providers, CMS points out that they drain a disproportionate amount of Medicare Administrative Contractor (MAC) resources. 

The policy was announced in Transmittal 495 to Medicare’s Program Integrity Manual, which states that these providers are abusing Medicare by failing to change after repeated education. This policy can be used now, but is being formalized in Medicare manuals effective Jan. 15, 2014.

It will be up to the MAC to request that CMS look at a provider as a recalcitrant provider. In its policy, CMS says that these providers should not currently be under a fraud investigation, should be on prepayment review at the time of the request, the administrative burden of the provider is known, the provider does not have a successful appeal history and the Medical Director agrees with the medical review determinations.

Once that information is submitted to CMS, the agency will decide whether to include the provider as a recalcitrant provider based on the types of services and volume of services found to not be medically necessary and the pattern of behavior of the provider identified. 

The attached transmittal shows the format the MAC must follow in order to go after a recalcitrant provider. The bottom line is, the agency is raising the stakes for providers, making sure that education is being done to correct mistakes and that practices are making a good faith effort to bill correctly, and not allow the MACs medical determination process to be the approach to correct bad claims.

Recalcitrant Providers transmittal (pdf) 


CMS looking for ways to boot providers who don’t correct repeated billing problems. (2015, December 2). Find-A-Code Articles. Retrieved from

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