By Vanessa Cross, J.D., LL.M.
After an on-sight visit by a CMS administrative contractor, Adora Healthcare Services, Inc.'s (Adora) Medicare enrollment and billing privileges were revoked after an initial determination that it was non-operational at its duly enrolled practice location in Houston, Texas. Upon reconsideration, the CMS determination was upheld even after Adora provided proof that it had moved locations of its operation in Houston and had sent notice of its address change. On May 17, 2017, a Departmental Appeals Board (DAB) decision was upheld by the Appellate Division, determining that, upon reconsideration by CMS, a revocation was not appropriate after the provider showed proof that it had moved and operates at a new location and either provides notice of the change of address, as required by regulation, or the time to report a change of address was not expired at the time of an on-site inspection at the old address. (Adora Healthcare Services, Inc. v. CMS, Docket No. A-16-119, Ruling No. 2017-4, May 18, 2017).
Revocation and appeal. Adora's Medicare enrollment and billing privileges were revoked CMS based on its initial determination that Adora was found non-operational on July 7, 2014, under 42 C.F.R. section 424.535(a)(5). Adora sought reconsideration of the CMS revocation, asserting that, effective July 1, 2014, it timely notified CMS of its move to a new practice location. To support its claim for reconsideration, Adora presented evidence that included a change of address notice mailed to the contractor hearing officer on June 26, 2014. In its reconsideration decision, the CMS contractor upheld the revocation based on the CMS contractor having no record of receiving a change of address notice.
On appeal, an administrative law judge (ALJ) reversed the CMS reconsideration and the revocation, citing 42 C.F.R. § 424.516(e)(2)'s requirement that "[a]ll other changes to enrollment must be reported with 90 days." CMS appealed to the Departmental Appeals Board (DAB). DAB affirmed the reversal on different grounds, namely, that the revocation was invalid because CMS's determination that Adora was 'no longer operational' rested solely on the inspector's duly enrolled location. The DAB found the CMS determination to be premature based Adora’s 90-day reporting period for providing notice of a change of address not having expired.
Final decision. The Appellate Division declined CMS’s request for reconsideration of its decision, based on it not having shown a clear error or law or fact. The regulation supports an interpretation that a move to a new address is not ceasing operations for purposes of invoking section 424.516(e)(2). Upon a CMS reconsideration hearing, sustaining a revocation is not appropriate where a Medicare provider or supplier is able to demonstrate that it has moved and is operating at a new location by providing proof of a change of address or reporting a change of address before the time for reporting has not expired.
Company: Adora Healthcare Services, Inc.
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