A Medicare revocation issued under 42 C.F.R. 424.535 ends billing privileges as of the effective date stated in the revocation notice. The provider retains a right to challenge it, and that challenge runs on a different track than a claims appeal over extrapolation, a recoupment demand, a RAC finding, or a local coverage determination the claims failed to meet. Reconsideration comes first, then, if that is unfavorable, a hearing before an administrative law judge (ALJ) at the HHS Departmental Appeals Board (DAB), then further review. Each stage has its own decision maker, its own evidence rules, and its own effect on whether the provider can keep billing Medicare while the fight continues.
The Reconsideration Request and Its Evidence Rule
Whatever the audit behind it, a home health documentation review, a hospice eligibility review, or an HCC coding and risk adjustment review, reconsideration is the first step in challenging the revocation itself. The request is filed with CMS or its Medicare Administrative Contractor and decided by a reviewing official who took no part in the original revocation. It must identify the specific findings in dispute and state the reasons, with the documentation, affidavits, and corrected records that answer them. A corrective action plan is a separate remedy. What makes reconsideration the stage that matters most is a rule in the Medicare enrollment appeals regulations: new documentary evidence not submitted at reconsideration is excluded if offered for the first time at the ALJ hearing, absent good cause for the delay.
The ALJ Hearing at the Departmental Appeals Board
If reconsideration is unfavorable, the provider may request a hearing before an ALJ at the DAB. The hearing is adversarial: CMS appears as a party, and the provider presents whatever evidence survived the good-cause screen from reconsideration. The ALJ's review does not start over. It stays within the existing record and the issues reconsideration already decided; new provider enrollment issues are not raised for the first time at this stage. Getting excluded evidence admitted does not undo the underlying finding, the missing signature, the lapsed license, the unreported address, when the finding itself is accurate. That narrow scope is why the evidence assembled at reconsideration carries so much weight.
The ALJ hearing tests the record built at reconsideration. It does not start a new one.
Further Review Beyond the ALJ
A provider dissatisfied with the ALJ's decision may ask the DAB's Appellate Division to review it, on the existing record rather than a new hearing with new witnesses. If that review is still unfavorable, the provider's last step is judicial review in federal district court under 42 U.S.C. § 405(g), the same provision that governs judicial review of other Medicare appeals. A federal court reviewing a revocation case applies a deferential standard to the agency's findings, so a legal argument, that CMS misapplied the regulation, carries more weight at this stage than a factual dispute already decided against the provider twice.
Billing Status While the Appeal Is Pending
None of these stages pause the revocation. Billing privileges end on the effective date stated in the notice and stay ended through reconsideration and the ALJ hearing while the case is pending. Neither the Medicare Administrative Contractor nor the ALJ has authority to stay a revocation simply because the provider has appealed it. Winning at any stage, reconsideration, the ALJ hearing, or further review, gets billing privileges restored, but that relief arrives only when the appeal concludes, not while it is underway. A provider deciding whether to keep operating or refer patients elsewhere during an appeal has to make that call without assurance reinstatement arrives before the business consequences do.
Why Early Legal Counsel Is Critical
It is critical that providers promptly retain experienced healthcare defense counsel upon receiving a Medicare revocation notice, rather than waiting to see how reconsideration turns out. Early legal intervention shapes what goes into the reconsideration record, the stage the good-cause rule makes difficult to supplement later, and helps the provider weigh realistically whether reconsideration, the ALJ hearing, or further review offers the better chance of reversal. Delaying counsel until after reconsideration has already been filed can foreclose arguments and evidence that were available at the outset.
How Health Law Alliance Can Help
Health Law Alliance represents providers through every stage of a Medicare revocation appeal, from the reconsideration request through the ALJ hearing at the Departmental Appeals Board and further review, as part of the firm's Medicare audit defense practice. The firm has also secured reinstatement for a DME supplier whose Medicare billing privileges had been revoked. If your practice has received a revocation notice, contact us for a free, confidential consultation.
