Federal Health Care Provider Exclusion


Though much has been said and will continue to be said about the Affordable Care Act, the impact of Medicare revenues (or the lack thereof for those opting out) will be an important economic issue to all practitioners.

Being forcibly excluded from Medicare as a provider can have a pervasive and profound adverse effect upon the reputation and economic dynamics of a practice. Being excluded as a provider is not equivalent to voluntary opting out.

When a practitioner is excluded from Medicare, that exclusion is supposed to extend to all federal programs. In addition, managed care companies see such an exclusion as a severe reputational issue and an opportunity to also exclude the practitioner. Likewise, state licensure boards, workers compensation regulators, hospital peer review, and specialty boards may likewise exclude a practitioner based upon Medicare or Medicaid exclusion.

In Texas, Medicare quality of care is reviewed by the Texas Medical Foundation, not to be confused with the Texas Medical Association. The TMF reviews charts, responds to complaints, and holds hearings that may result in exclusion proceedings on the federal level. This Firm has been involved with defending physicians in the TMF process for more than 20 years. The unique procedures for TMF review and decision can be confusing, frustrating, and painful for the unprepared provider. Providers who receive a TMF notice should seek legal counsel immediately, prior to responding to the stated concerns.

In Texas, Medicare reimbursement is reviewed by CMS through its subcontractors. The subcontractors are essentially paid on the basis of the dollars recovered/disallowed in cases where they find charting deficiencies which do not support the billing code used. (See. Medicare and Medicaid Reimbursement under “Practice Areas”, at this website).

It is extremely important for any provider who is facing the threat of sanction by TMF or CMS to seek experienced legal counsel as soon as possible.