When a CMS audit uncovers documentation errors or compliance issues, the consequences often quickly escalate from a routine review to the catastrophic event of revocation. In fact, revocation is arguably the most powerful weapon in CMS’s arsenal, and it is a weapon we have increasingly seen utilized in 2026. Revocation means that your practice can no longer bill Medicare, claims will go unpaid, and you may face a re-enrollment bar locking you out of the program for up to ten years. Additionally, the rippling effect of having your Medicare billing privileges revoked is severe, as commercial health insurers, state Medicaid programs, and other third-party payors will frequently use a CMS revocation as grounds to immediately terminate your network participation agreement. However, providers are not without recourse, and, if you are in receipt of an initial determination from CMS revoking your billing privileges, acting quickly and strategically is essential.

How to Challenge CMS’s Administrative Action

The appeals process involves strict deadlines and procedural requirements that providers must pay close and careful attention to. Missing a deadline or failing to submit the right documentation early on can derail your entire defense. The administrative appeals process generally unfolds as follows:

• Corrective Action Plan: Prior to diving into a formal appeal, providers or suppliers subject to revocation for certain deficiencies, such as general noncompliance, may have a brief window to submit a Corrective Action Plan (“CAP”) that addresses the specific, eligible deficiency. If eligible, a CAP must be submitted within 35 calendar days of the date on the revocation letter that the provider received. The CAP must generally include verifiable evidence demonstrating that the provider or supplier has corrected the cited deficiency and is back in full compliance with Medicare requirements. If approved, the provider or supplier may have its billing privileges retroactively reinstated.

• Reconsideration: If a CAP is not an option, or if it is denied, the first formal level of appeal is Reconsideration. This is an independent review conducted by a CMS contractor not involved in the initial revocation decision. Reconsideration requests must be in writing and received by the applicable CMS contractor within 65 calendar days of the date of the initial revocation letter. Crucially, a provider or supplier must submit all additional information, arguments and documentary evidence that they seek to have considered for the entire appeals process during this stage. If the provider or supplier fails to submit evidence during Reconsideration, they are generally barred from introducing it at any other stage in the appeals process. As such, it is paramount that providers and suppliers are treating this stage as the foundation for their defense by capturing the full legal picture, anticipating potential counterarguments and meticulously assembling every piece of supporting evidence.

• Administrative Law Judge (“ALJ”) Hearing: If dissatisfied with the reconsideration determination, a provider or supplier is entitled to request a hearing before an ALJ within 60 days of the receipt of the reconsideration determination. This is a formal, adversarial process where a CMS attorney will actively defend the agency’s decision in front of a neutral adjudicator. A request for an ALJ hearing must identify specific issues and the findings of fact and conclusions of law that the provider or supplier disagrees with. Additionally, the provider or supplier must specify the basis for contending that the findings and conclusions are incorrect. It is important to note that an ALJ generally cannot substitute their own discretion for CMS’s, as their review is strictly limited to whether CMS had the legal authority to revoke a provider’s or supplier’s billing privileges based on the record.

• Departmental Appeals Board (“DAB”) Review: If the ALJ issues an unfavorable decision, either party (the provider/supplier or CMS) may request a review by the DAB within 60 days of such decision. The DAB serves as the final administrative decision-maker in the revocation appeals process and will review the existing record to determine if the ALJ’s decision was legally and factually sound. At the conclusion of the DAB review, the provider or supplier will have exhausted their administrative remedies.

• Judicial Review: If a provider or supplier has exhausted all administrative remedies and the DAB decision is still unfavorable, they have the right to seek judicial review by filing a civil action in Federal Court. This step is rare, and it is typically only appropriate when there was a significant legal or procedural error in how the agency handled the provider’s or supplier’s case.

How We Can Help

Medicare billing privileges revocations are not routine administrative matters; they are existential threats to you and/or your organization. Because the appeals process involves complex technicalities, unforgiving deadlines, and the absolute need to build a comprehensive evidentiary record early on, proactive engagement with legal counsel is highly recommended.

MDRXLaw routinely works with healthcare providers and suppliers facing administrative actions that negatively impact their organizations and billing privileges. We can help you analyze the initial determination, structure a comprehensive Corrective Action Plan, and aggressively defend you through every level of the appeals process. We also help organizations implement compliance policies, strengthen documentation practices, and proactively manage risks. If you or your organization are in receipt of a revocation notice from CMS, or want to learn more about how to bolster your proactive compliance measures, please feel free to contact our healthcare attorneys at (212) 668-0200 or via email at info@mdrxlaw.com.