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    The nightmare scenario for any doctor: Things are humming along, business as usual. Then one day a reimbursement claim gets denied. A major insurance payor says your participation is terminated, with no explanation.

    There are worse omens out there, but most of them involve seas boiling and vindictive fortune tellers.

    When one of Ideal Business Partners’ clients found himself in this situation, IBP went to work. Our attorneys dealt with the insurance payor before finally confirming that the physician in question was on the Centers for Medicare & Medicaid’s Medicaid Integrity Group list.

    The big problem? After more digging, we found the doctor should never have been blacklisted. He had been improperly reported after entering into a settlement that stemmed from billing errors five years prior.

    An IBP attorney was then told by the insurance payor that obtaining written documentation from CMS, proving our doctor wasn’t on the list, was the only way to remedy the situation.

    That wasn’t good enough for IBP. Having worked with CMS and its related agencies before, it was apparent that no such written documentation would be forthcoming. Calls went out to the various federal and state agencies , which denied that our doctor was excluded or barred. When an IBP attorney checked with the folks at Nevada Medicaid, they said didn’t put the doctor on the list, so they couldn’t take him off.

    Additional calls to CMS confirmed not only that the doctor was blacklisted, but that it was Nevada Medicaid which put him there. At this point, you’re probably wondering if there might be something to be said for a central federal database that all the states feed into. That’s a reasonable question, and one which highlights just how much these agencies can exist within their own silos.

    IBP took matters into its own hands to inform Nevada Medicaid that the physician in question was, in fact, on the federal blacklist. IBP argued, correctly, that he should not have been. The state finally consented to doing an investigation and, lo and behold, discovered the doctor didn’t belong on the list after all. In the end, though it is not possible to be removed from CMS’ termination list once your name has been included, IBP was able to get the provider’s status updated to reflect that the termination was rescinded, and that his inclusion on the list was in error.

    There’s no due process for cases like this. There isn’t even a notification when a doctor is placed on these kinds of lists, and most individuals don’t have access to them in the first place. It’s the kind of casual bureaucratic error than can end an innocent physician’s practice. If you ever find yourself in a similar situation, give us a call. Don’t wait for the seas to boil first.

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