Welcome to The Provider Enrollment Digest

Posted by medpro | Posted in Credentialing, Medical Contracting, Physician Credentialing, Physician Review, Provider Contracting, Provider Enrollment | Posted on 18-10-2010


Welcome to a blog created to furnish a venue for interested parties to exchange information, news and notes about what can sometimes be an overwhelming subject…. Provider Enrollment…. That is getting all manner health care providers credentialed and contracted with the dizzying array of insurance entities. A list of which runs the gamut from Medicare/Medicaid oriented government entities to the large commercial firms like Aetna, Cigna, Blue Cross/Blue Shield, Humana and UnitedHealthcare to a plethora of HMO’s and PPO’s and all manner of organizations in between.

For anyone who has attempted to undertake a contracting or credentialing effort they know what an complex, frustrating and time consuming activity it can be. Each insurance entity has it’s own unique network needs, processes and procedures. Some make it simple and easy and have excellent network management representatives while others make it a bit more difficult. Add the possible variations  together and you end up with a mind boggling amount of work, time, phone calls and, not too infrequently, frustration. Not for the faint of heart.

What we hope to accomplish is to provide you with general data and information that you’ll find helpful and relevant to and during the provider enrollment process. It addition we hope to offer you info and insights that will help enhance the interface with your own payor universe.

I’m sure we don’t have to tell you that the healthcare industry in a state of flux. As a consequence it has never been more important to insure that your relationship with the public and private payor community is strong and clear.  All of that begins with the proper approach to contracting and credentialing.  So come on along. Bookmark this site or subscribe to the RSS feed, contribute to the comments page, contact us with questions or topic suggestions. The fog of confusions is only dispersed by information and dialogue.

CMS Issues Ruling on Provider Enrollment

Posted by medpro | Posted in Credentialing, Medical Contracting, Provider Enrollment | Posted on 20-06-2012


As of June 26, 2012, the new provider enrollment rule requires that all providers and suppliers eligible for a national provider identifier (“NPI”) must:

  • Report their NPIs on their Medicare enrollment application;
  • Update their enrollment record if the provider or supplier was in the Medicare program prior to obtaining an NPI or if the NPI is not in the provider or supplier’s enrollment record; and
  • Include their NPIs on all claims submitted to Medicare for payment, and the NPIs of any other provider or supplier identified on the claim.

The anticipated effects of implementing these new rules will result in $1.59 billion in savings over the next ten years.  This is a consequence on  CMS’ aggressive approach to provider enrollment by helping to ensure greater quality and integrity on the front end in the provider enrollment process.

New “Board Eligible” Policy

Posted by medpro | Posted in Provider Enrollment | Posted on 14-03-2012


The American Board of Medical Specialties has established a new policy to limit the amount of time a provider can be classified as “ board eligible”. The new rule requires doctors to be certified from 3 to 7 years after completing their residency. The idea behind the new rule is to help eliminate the confusion surrounding the term “board eligible”. Some doctors use this connotation to describe themselves during a provider enrollment process or in materials presented to patients, when in fact, they are not actively pursing board a certification. The ABMS feels that this can result in confusion, giving the impression that they are nearly equivalent to an actual board certified physician when in fact they aren’t. This may overstate the physician’s competencies since they have not been required to maintain their specialties’ proficiencies, as required by a board certification procedure. The time limits allowed with vary with specialty, with each board having to set the time limit policy by April 16.

Some boards already have policies in place but they need to bring them in line with the overall ABMS policy. An example, family physicians are certified within three yeas of completing their residency. If they aren’t certified after 7 years they must complete at least one more year of family medicine residency.

Physicians who have begun the certification process will have to complete it between 2015 and 2019.

For more information click here

Revisions to the Medicare Provider Revalidation Process

Posted by medpro | Posted in Provider Enrollment | Posted on 04-11-2011


The Centers for Medicaid & Medicare Services (CMS) has lengthened the  time frame that physicians have to revalidate their Medicare provider enrollment authorized under the program integrity screening provisions of the Affordable Care Act.  According to CMS, the revalidation effort, originally scheduled for March 23, 2013, will be pushed back through 2015. Physicians will be among the last of the provider groups to revalidate.  Revalidation process is designed to help reduce Medicare fraud and abuse.

How to Pay the New Provider Enrollment Fees

Posted by medpro | Posted in Credentialing, Provider Enrollment | Posted on 06-10-2011



As mentioned in a previous post new fees have been accessed on certain types of providers as part of the Medicare enrollment and revalidation processes. You can refer to that post to find out more about who exactly is required to pay the $505 fee. The CMS has recently made a couple of tweaks to the system to simplify the Provider enrollment fee payment process. For providers enrolling or revalidating using the PECOS on line system they will you will no longer need to separately access Pay.gov to make the fee payments. Instead, as they proceed through the PECOS application and if a fee is required, they will be prompted to submit a payment and will automatically be transferred to the Pay.gov website. There they can make the payment by credit ordebit card. Once your payment transaction is complete, they will be automatically returned to the PECOS website to complete the remainder of the application.

For those providers who use the 855 paper application, they can access Pay.gov using the following URL: https://pecos.cms.hhs.gov/pecos/feePaymentWelcome.doto enter and submit payment. After making the payment the applicant will receive a receipt. It’s important to make a copy and attach it to the completed CMS-855 application submitted to your Medicare contractor.


Part B MAC’s Receive Low Marks For Their Provider Enrollment Processes

Posted by medpro | Posted in Provider Contracting, Provider Enrollment | Posted on 23-09-2011


Each year the CMS conducts a survey among Medicare providers and suppliers. It is designed to measure the level of satisfaction with all Medicare program contractors. This year’s survey has just been released.

Some of the key findings:

  • The average score for all contractors when based on overall satisfaction was 3.77 and 3.64 when measuring satisfaction by business function. Scale is based on a 5.0 top score.
  • There wasn’t a great deal of variance in the scores. The highest by contractor category was Regional Home Health Intermediaries at 3.77. The lowest category was Part B MAC’s with a score of 3.56
  • There was little change in the scores between 2010 and 2011.
  • Within the business function category Reimbursement and Claims Processing scored the highest at 76 percent satisfied or highly satisfied. Provider enrollment process scored significantly lower at a 53% satisfaction rate.
  • The lowest satisfaction level was registered in the survey was with Part B MAC’s performance  in the area of Provider Enrollment, with a 47% rate.

The overall general satisfaction levels by specific MAC is shown below:






All Medicare Provider and Supplier Payments to be made by Electronic Funds Transfer

Posted by medpro | Posted in Credentialing, Physician Credentialing, Provider Enrollment | Posted on 22-09-2011


In conjunction with the revaildation effort mentioned in the last post, existing regulations at 42 CFR 424.510(e)(1)(2) require that at the time of enrollment, enrollment change request or revalidation, providers and suppliers that expect to receive payment from Medicare for services provided must also agree to receive Medicare payments through electronic funds transfer (EFT). Section 1104 of the Affordable Care Act of 2010 (ACA) further expands Section 1862 (a) of the Social Security Act by mandating federal payments to providers and suppliers only by electronic means. As part of CMS’s revalidation efforts, all suppliers and providers who are not currently receiving EFT payments will be identified, and required to submit the CMS 588 EFT form with the Provider Enrollment Revalidation application.

Revalidation of Medicare Provider Enrollment Information

Posted by medpro | Posted in Credentialing, Medical Contracting, Provider Enrollment | Posted on 09-08-2011


If a Medicare provider or supplier enrolled prior to March 25, 2011, they are required under the terms of the Affordable Care Act to revalidate their provider enrollment information. Providers and suppliers must wait to submit the revalidation until they receive notice from ther MAC to do so. Between now and March 23, 2013, MACs will send out notices on a regular basis to begin the revalidation process for each provider and supplier.

Newly enrolled providers and suppliers that submitted their enrollment applications to the Centers for Medicare & Medicaid Services (CMS) on or after March 25, 2011, are not required to revalidate.

When you receive notification from your MAC to revalidate you need to:

• Update your enrollment through Internet-based Provider Enrollment, Chain and Ownership System (PECOS) or complete the appropriate CMS-855 form

• Sign the certification statement on the application

• All institutional providers and suppliers who respond to a revalidation request mustsubmit an enrollment fee via Pay.Gov (reference 42 CFR 424.514). You may submit your fee by electronic check, debit, or credit card.

• Mail your supporting documents and certification statement to your MAC

Upon receipt of the revalidation request from their MAC, providers and suppliers have 60 days from the date of the letter to submit complete provider enrollment forms. Failure to submit the enrollment forms as requested may result in the deactivation of your Medicare billing privileges.

Here is the link to the MLN Matters article SE1126 .

Attempt to Regulate the Provider Enrollment Process

Posted by medpro | Posted in Credentialing, Medical Contracting, Physician Credentialing, Provider Contracting, Provider Enrollment | Posted on 20-07-2011


An interesting bill was introduced in the State of Pennsylvania General Assembly, House Bill No. 1551 entitled The Physician Credentialing Act. The primary purpose of the act is to provide for an ”equitable and expeditions initial provider enrollment process” by “promoting fairness to the health care providers by ensuring that health insurer conduct physician credentialing in a reasonable time frame and reimburse physicians during the credentialing process.” Nobel sentiments for those of us intimately involved in the credentialing process.

The details:

  • the insurer must complete the initial credentialing process within 60 days of receiving a completed application.
  • The insure must report to the physician or designee the status of the application with 5 days of receipt telling him/her whether the insurer intends to process the application, date of the next credentialing review and an itemization of the application deficiencies.
  • The insurer must notify the applicant of the credentialing committee decisions with in 5 business days.
  • Once the insurance company has notified the applicant that they will proceed with the application, the provider will be eligible for reimbursement within 15 days of the application submittal. Reimbursement will based on the nonparticipating physician fee schedule. Or in the case of an individual joining a contracted group at the group’s current rates
  • An insurer must accept CAQH if submitted by a physician.
  • A insurer not adhering to these new rules is liable for damage claims made by physicians plus they can incur a $5,000 state penalty.
  • A physician has the right to appeal to the State Secretary of Health an application rejection, under certain circumstances.

Some interesting issues here, although it appears to apply to physicians only and it is a bit one sided in that regard. Not sure that the insurance companies will be pleased with all these new restrictions and controls, so there may be some struggles and/or changes along the way. However it is encouraging to see recognition by lawmakers of the difficulties and complexities associated with the provider enrollment process. Difficulties and complexities on both sides of the transaction and that a bit of standardization could help resolve some of the more egregious. We wish them well.

What do you think about the Bill and it’s prospect for passage?  Leave a comment.


New Telemedicine Provider Enrollment Procedures

Posted by medpro | Posted in Credentialing, Physician Credentialing, Provider Enrollment | Posted on 01-06-2011


As mentioned in a previous post the CMS has instituted new rules regarding provider enrollment requirements for telemedicine applications. Under the previous system, a provider supplying the telemedicine service would need to be credentialed at both medical facilities. This created an unnecessary level of paperwork, time and duplication of effort. The CMS recognized the problem and issues the new rules which allows the receiving hospital to accept the credentials of the telemedicine providing entity. However there are some procedures and caveats that apply.

There are two sets of rules that apply one for hospitals and the other for independent telemedicine entities (ie non-hospital provider organizations that offer telemedicine services). There must be a written agreement between the providing and the receiving medical entity. That agreement must contain certain provisions. For hospitals the lists include the following:

  • The physician providing the telemedicine services must be privileged at the originating hospital and that hospital must provide a list of those privileges.
  • The hospital providing the telemedicine services must be medicare participating.
  • The physician providing the services must be licensed in the state where the patient is receiving the telemedicine services.
  • The hospital receiving the telemedicine services must submit a performance review of the telemedicine to the originating hospital.
  • The privileging hospital must adhere to the standards set out in 42 C.F.R. §§ 482.12(a)(1)-(7) , 42 C.F.R. §§ 485.616(c)(1)(i)-(vii) and 42 C.F.R. §§ 482.12(a)(8), 482.22(a)(3) and 485.616(c)(2).

With telemedicine entities again both parties must enter into a written agreement that include the following provisions.

  • The physician must be privileged at the entity that providing the telemedicine services and that entity must provide a list of those privileges.
  • The providing telemedicine entity must comply with all CoP’s related to providing a contracted medical services.
  • The credentialing standards of the telemedicine entity must meed the standards set out in 42 C.F.R. §§ 482.12(a)(1)-(7) and 42 C.F.R. §§ 482.22(a)(1)-(2) or 42 C.F.R. §§ 485.616(c)(1)(i)-(vii).
  • Again the physician/provider must be licensed in the state where the patient is receiving the service.
  • The same internal review procedures as is the case with hospitals.

It important that both parties participating in a telemedicine relationship spent a bit of time up front to insure that the written agreement is in order and that the proper provider enrollment standards are in place.

Another Reason to Check Your Provider Enrollment, Chain and Ownership System (PECOS) Record

Posted by medpro | Posted in Credentialing, Medical Contracting, Physician Credentialing, Provider Enrollment | Posted on 16-05-2011


Back in December of 2010, CMS launched a new web site called Physician Compare. The site is specifically designed to provide consumers with information to help them identify and locate a Medicare enrolled provider in their geographic area. The consumer goes to the web site, enters the type and gender of provider he or she is seeking, his or her zip code and whether or not they are looking for participating or non-participating provider. The site then generates a list arranged by distance from consumers location. Information provided includes the physician’s name, address, phone number, distance from consumers location, language capabilities and Medicare participation status (ie participating/non participating)

However it appears that a number of physicians have found that the information contained on their record is incorrect. The common errors include:

  • Name misspellings
  • Incorrect Medicare participation status
  • Inconsistent results derived from location-based searches
  • Listings include doctors who no longer practice.

The Information contained on the Physician Compare site are derived from the Medicare Provider Enrollment, Chain and Ownership System (PECOS), so any information that is missing or incorrect on that file will likely transfer to the Physician Compare web site.

A couple of obvious issues here:

  • If you haven’t taken a look at the Physician Compare site and checked the information…do so.
  • If the information on the Physician Compare is incorrect go to your PECOS record and change it. While your there check all the other information on the record to make sure it’s correct and up-to-date.
  • Even if the Physician Compare information is correct, if you haven’t updated your PECOS record in the last 5 years, it’s a good idea to access it anyway and check all the info. CMS will continue to use this record as the definitive source document for any and all current and future data bases.

If you do uncover a problem, CMS provides some additional guidance to help fix errors in the listings, see http://www.medicare.gov/find-a-doctor/staticpages/note/overview.aspx

For doctors who are properly enrolled in Medicare (in the PECOS database) yet unlisted on the Physician Compare website, compare the information on PECOS to your listing in the NPI registry at https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do and correct any inconsistencies. If none are found then send your name, NPI, and city/state location to Rodney Peele in the AOA Washington Office at rpeele@aoa.org.

CMS has pledged to try to fix the flaws in the mapping software and to investigate the reason why many doctors remain unlisted in their geographic location.

The Physician Compare web site is just the first step in CMS’s overall plan to provide the Medicare consumer and consumers in general with more information about healthcare providers. Next up are quality measures, sure to ruffle some feathers. However at this early stage it’s key that an enrolled provider basic information is correct and up to date.