Fundamentals of Medicare

Section 1: Introduction


Voluntary and Involuntary Termination of Provider Agreement

Table of Contents

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Voluntary and Involuntary Termination of Provider Agreement

For various reasons, providers may find it necessary to voluntarily terminate their participation with the Medicare Program. In other circumstances, providers may have to be involuntarily removed from the Medicare Program.

The CMS IOM Publication 100-01, Medicare General Information, Eligibility and Entitlement Manual, Chapter 5, Section 10.6.1 regulation states a provider may voluntarily terminate its participation in the program or have participation involuntarily terminated by CMS.

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Voluntary (Provider-Requested) Termination of Agreement

If a provider would like to terminate its agreement with Medicare, instructions can be found in the CMS IOM Publication, 100-01 Medicare General Information, Eligibility and Entitlement Manual, Chapter 5, Section 10.6.1.

The regulations state a provider may terminate its agreement to participate with Medicare by:

  • Filing a written notice to CMS stating its intention to terminate, and
  • Informing CMS of the official date the termination takes effect. CMS may take the date notated or set a different date. The termination date must be the first date of a month.

As soon as the termination date is established, CMS will instruct the provider to notify the public it is voluntarily terminating its provider agreement. The public notice should be published in the local paper with the largest circulation as soon as possible but not less than 15 days before the effective termination date. The provider should also file a CMS-855A to request a voluntary termination of its Medicare billing number.

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Involuntary Termination (CMS Cancellation of Provider Agreement)

Medicare regulations also state CMS may terminate a provider’s Medicare agreement if it has determined the provider:

  • Is not complying with Medicare guidelines and/or regulations
  • No longer meets the appropriate requirements for participation
  • Has failed to supply cost report information or
  • Refuses to participate in audits of financial and/or medical records.

Whether the termination is voluntary or involuntary, CMS notifies the provider of the termination effective date via written correspondence. As of that date, no further payment will be made by the Medicare Program.

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Payment Exceptions

Payment can continue to be made for up to 30 days for inpatient hospital services, swing-bed extended care services and/or SNF post-hospital extended care services furnished on or after the termination date to beneficiaries who were admitted prior to the termination date.

Payment may be made for services under a plan of treatment for up to 30 days following the effective termination date of a home health agency or hospice if the plan was established before the termination date.

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Collecting Overpayments from Terminated Providers

If the contractor discovers an overpayment due from a terminated provider (defined as no longer participating with Medicare or Medicaid), the provider will be contacted with a request for a lump sum payment. Additional collections activities will follow, as appropriate.

However, if the provider is no longer with Medicare but still participating in the Medicaid program, action to withhold a Federal share of Medicaid payments can be initiated, as appropriate.

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Reviewed 6/4/2024