Medicare Revocations and Corrective Action Plans

A revocation is worse than a denial because you were already in. Medicare stops paying, any provider agreement ends, a reenrollment bar begins, and the revocation can follow you into Medicare Advantage through CMS's preclusion list. The regulations give you two ways back: a corrective action plan (CAP), which lets you fix certain problems, and a reconsideration, which lets you argue that CMS got it wrong. They have different deadlines, and both clocks start on the same day.

Why was the enrollment revoked?

The grounds are in 42 CFR 424.535(a). Among them: noncompliance with enrollment requirements (a)(1), an excluded or debarred person in the practice (a)(2), a felony within 10 years (a)(3), false information (a)(4), a location found not operational on a site visit (a)(5), abuse of billing privileges (a)(8), failure to report required changes (a)(9), and a pattern of abusive ordering or prescribing (a)(21). The revocation letter must state the reason "in sufficient detail for the provider or supplier to understand the nature of its deficiencies" and describe your appeal rights (42 CFR 405.800(b)).

Identify the paragraph first. It controls the effective date, the length of any bar, and whether a CAP is available at all.

When does the revocation take effect?

The default in 424.535(g)(1) is 30 days after CMS or the contractor mails the notice. Many grounds carry an earlier date under (g)(2): the date of an exclusion, a felony conviction, a license suspension, the date the location stopped being operational, or the day after a change you failed to report was due. If the conduct happened before your enrollment began, the revocation reaches back to the enrollment date itself ((g)(3)). Claims for services with a date on or after the effective date are rejected (405.800(b)(3)).

You also have a claims deadline. Under 424.535(h), a revoked provider "must, within 60 calendar days after the effective date of revocation, submit all claims for items and services furnished before the date of the revocation letter." Do this even while you appeal.

How long is the reenrollment bar?

Under 424.535(c)(1), the bar "begins 30 days after CMS or its contractor mails notice of the revocation and lasts a minimum of 1 year, but not greater than 10 years," depending on severity. CMS can add up to 3 years if it finds you tried to get around the bar under a different name or identifier, and can impose up to 20 years for a second revocation. One important exception: the bar does not apply when the revocation is under (a)(1) for failing to respond in time to a revalidation request or other request for information ((c)(1)(ii)). Our sister service explains how Medicare revalidation works, which is where many (a)(1) revocations start.

The original length of the bar is not appealable. Under 405.800(c)(2), only years added under 424.535(c)(2)(i) can be appealed.

What is a corrective action plan, and who can use one?

The CAP regulation is 42 CFR 405.809. It says a provider "may only submit a corrective action plan for a revocation for noncompliance under § 424.535(a)(1)" and "has only one opportunity to correct all deficiencies that served as the basis of its revocation." If CMS or the contractor accepts the CAP, it reinstates billing privileges with an effective date "based on the date the provider or supplier is in compliance with all Medicare requirements." If it refuses, that refusal "is not an initial determination" and cannot itself be appealed.

So a CAP is not an argument. It is proof. CMS's Program Integrity Manual (Chapter 10, section 10.6.18) says a CAP "must contain, at a minimum, verifiable evidence that the provider/supplier is in compliance with all applicable Medicare requirements." Think updated license verifications, a corrected practice location with photos and a lease, a completed revalidation, or a reported change with the confirmation.

What are the CAP and reconsideration deadlines?

The regulation sets the reconsideration deadline: 42 CFR 498.22(b)(3) requires the request "within 60 days from receipt of the notice of initial determination," with receipt "presumed to be 5 days after the date on the notice." Section 405.809 sets no CAP deadline in its text. The CAP window comes from the Program Integrity Manual, which states:

• A CAP "must be received by the MAC or CMS within 35 calendar days of the date of the initial determination."
• A reconsideration request "must be received by the MAC or CMS within 65 calendar days of the date of the initial determination."
• Filing a CAP does not pause the reconsideration clock: "The provider/supplier must submit a reconsideration request within 65 days of the date of the initial determination, even if a CAP is timely submitted and accepted."

The manual tells the hearing officer to decide a CAP within 60 calendar days of receiving it and a reconsideration within 90. Because the CAP decision can arrive after day 65, the safe course for an (a)(1) revocation is usually to send both: the CAP showing you are now compliant, and a reconsideration request contesting anything in the revocation you believe was wrong. The manual also states that CAPs and reconsideration requests must each be a letter signed by the individual practitioner, an authorized or delegated official, or a properly appointed representative.

Is there a quicker fix when the problem is another person?

Yes. If the revocation rests on the sanction, exclusion or felony of an owner, managing employee, medical director, supervising physician or similar person, 424.535(e) allows reversal if you end the business relationship "and submits proof that it has terminated its business relationship with that party within 15 days of the revocation notification." Fifteen days is one of the shortest clocks in this area. Treat it as the first thing to decide.

How is a deactivation different?

Deactivation stops billing without revoking enrollment, often for non-billing or a missed revalidation. It has its own remedy: a rebuttal under 42 CFR 424.546, due within "15 calendar days from the date of the written notice." The rebuttal must be in writing, state what you disagree with and why, include all supporting documents, and be signed by you, your authorized or delegated official, or a legal representative. A deactivation determination "is not an initial determination" under 498.3(b), so there is no further appeal. CMS may extend the 15 days at its discretion.

Why does a revocation matter to Medicare Advantage plans?

Medicare Advantage plans must not pay for items or services furnished, ordered or prescribed by anyone on CMS's preclusion list (42 CFR 422.222(a)(1)). Under the definition in 422.2, a provider who is currently revoked, under a reenrollment bar, and whose conduct CMS finds "detrimental to the best interests of the Medicare program" can be placed on that list. If you receive notice of a revocation and preclusion at the same time, 42 CFR 498.5(n) requires a joint reconsideration of both. Our post on sanctions, exclusions and the preclusion list covers the plan side.

Which steps should happen in week one?

1. Write down the letter date. Count 15 days (business-relationship reversal), 35 days (CAP) and 65 days (reconsideration) from it.
2. Identify the 424.535(a) paragraph and the effective date the letter uses.
3. Start submitting claims for services before the letter date; the 60-day claims window runs from the effective date.
4. Gather compliance evidence for the CAP and error evidence for the reconsideration in separate folders. They answer different questions.
5. Decide whether you need a healthcare attorney. For revocations based on felonies, false statements or abusive prescribing, you almost certainly do.

Where do we fit in?

We are not attorneys and we never represent providers before CMS. We research and organize: the deadline calendar, the CAP evidence package, the reconsideration letter that sets out where the revocation is factually wrong, and the follow-up log. You review, sign and send each document. A Network Rejection Review is $249 and is credited toward a Payer Network Dispute at $799, as listed on our pricing page. If the next step is a hearing before an administrative law judge, see Medicare enrollment appeals beyond reconsideration, and bring in a healthcare attorney.