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.

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.

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.

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 .

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.

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.

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.

The CMS announced on May 5 2011 that it has finalized new rules for telemedicine services that will simplify the the provider enrollment and credentialing process. These changes were made to help ensure that patients, especially in rural or remote areas, will receive the best possible medical care from their local hospitals by making it easier for small and critical access hospitals (CAHs) to use telemedicine to link with physicians and other larger hospitals or academic medical centers. Under the old system practitioners could not provide care via telemedicine unless they were granted practice privileges both by their home hospital as well as by the remote hospital or CAH to which the telemedicine services were being delivered. Small hospital simply lacked the staff and resources to credential and privilege physicians participating the the telemeidicne services from remote hospitals.

Under the new rules each hospital and CAH will no longer be required to credential and grant privileges to each individual physician and practitioner who provides telemedicine services to its patients from a distant hospital or other telemedicine location. Instead, hospitals can employ the credentialing and privileging decisions of the distant hospital where the provider is currently privileged. The changes allow for what amounts to facility-to- facility credentialing and privileging as opposed to facility-to-physician. One caveat, the CMS telemedicine credentialing and privileging Conditions of Participation have been particularly challenging for hospitals using Joint Commission (TJC) accreditation for deemed status. That is because hospitals using the TJC “privileging-by-proxy” telemedicine standards have not technically been meeting CMS requirements – a situation which has obviously been problematic and confusing for hospitals. While the CMS final rule does more closely align with TJC “privileging-by-proxy” concept it is not yet clear how the new CMS regulations and TJC standards will align. While TJC is expected to conform to CMS regulations, you may want to wait for a response from TJC before implementing any changes.

The final rule goals are to reduce the burden of the traditional provider credentialing and enrollment process for Medicare-participating hospitals and CAHs, both those that provide telemedicine services and those that use such services. In particular, the rule extends the option of a streamlined credentialing and privileging process to those small hospitals and CAHs that use the telemedicine services in order to improve access to specialty services for patients.

On March 31, 2011 the CMS released the proposed regulations for implementation of the new Accountable Care Organizations (ACO) program. Discussions regarding the scope of these programs were covered in previous posts here, here and here.  ACO are part of CMS’s effort to reign in health care costs by becoming what it considers to be an aggressive procurer of healthcare services as apposed to someone who exists to simply pay the bills as they accrue. This new focus will manifest itself by altering provider’s actions from simply supplying a series of services to a focus on what the actual outcomes of the services provided are. Taking this approach is projected to significantly lower costs. To help motivate providers into adopt this new way of thinking, the CMS will offer an incentive in the form of a share in any savings that the ACO accrues.

The release of the proposed regulations last month give us an opportunity to review some concerns/issues surrounding the actual implementation of the program. Some of which have been around for a while and some of which are now arising as the rules and regulations are documented. It’s become clear that hospitals will likely take the lead in developing ACO’s. From their perspective there are a number of issues that need to be discussed and ultimately resolved. One important set of issues are the additional internal system requirements and the establishment of appropriate credentialing standards. For example: What standards, if any, are going to be established to determine whether a physician can participate in an ACO. Who is going to develop those standards? What standards, if any, are going to be employed to determine a physician’s on going participation in the ACO? Again who is going to develop those standards? Who within the organization will be responsible to gather all the data necessary for reporting purposes? What resources will they require?

The new proposed regulations add a new wrinkle by making the rewarded program a two-way street. There are two proposed reward options. In one option the ACO will be paid based on the current Medicare fee schedule, but if, at the end of the year, they have not met the agreed to goals, they must reimburse Medicare for a portion of the cost overruns. To compensate for the additional risk under this proposal the ACO would get a higher percentage (60%) of the savings. Under the second option, there would be no payback provision but the ACO would receive a lower percentage (50%)of the year end bonus. The second version is really designed only for the early years of an ACO. In the third year of it’s existence anyone using this approach must move to shared risk version. This begs the question, how and when are the savings bonuses to be distributed among ACO participating members?

The system developments, provider enrollment /credentialing and program decisions need to be thought through during the early stages of the ACO planning process. The ACO program start date is January 1,2012, less than 8 months away. Despite the various legal issues surrounding the Affordable Care Act it would appear that there is keen interests in the medical community to give the program a try and, at this point, there is little chance that anything will prevent it from commencing on the scheduled date.

The DMEPOS supplier industry has been singled by the Inspector General of the Department of Health and Human Services,Daniel Levinson, as an area of heightened fraud related concern. He noted during congressional testimony that, over the last three decades, HHS-OIG has detected “significant levels” of fraud and abuse related to durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). In addition, many DMEPOS suppliers are highly dependent on federal healthcare programs for revenue and CMS believes that a number of these types of providers enter business without any substantial clinical or business experience which in turn leads to a high level of non-fraud related errors and omissions. To help reduce these problems new, more stringent rules regrading DMEPOS provider enrollment and recertification have been enacted. The new rules went into effect on March 25, 2011.

As part of the new regulatory environment risk assessment categories of “limited”, “moderate” and “high” have been created. (More information here about the new classifications). Under the new rule currently enrolled DMEPOS suppliers will be automatically assigned to the “Moderate Risk” category while any new suppliers or those adding a new location will be assigned to the “High Risk” Category.

The practical applications of these category assignments are a significant, increasing the time and paperwork involved in newly enrolling entity’s credentialing process. The new procedures include extensive data base searches, including “The List of Excluded Individuals or Entities” and “ The Exclude Parties List” system of the GSA. On-site inspections will likely increase with Medicare contractors, The National Supplier Clearinghouse (authorized for both pre and post enrollment visits) as well as any national accreditation organization and state agencies with jurisdiction having the right and/or obligation to pay the supplier’s offices a visit. Criminal background checks of owners as well as fingerprinting of of all owners and managing employees are authorized.

For revalidating entities who are automatically assigned to the “Moderate Risk” category the process of making sure all the regulatory and licensing issues are current and up to date, while not quite as difficult, will likely be more through and time consuming. They too will be subject to on going data base checks and unannounced site visits.

In addition, if any existing DME supplier is subject to any of the issues detailed below they will be reassigned to the “High Risk” category and subject to the same provider enrollment restrictions.

• CMS imposed a payment suspension on the supplier in the last 10 years;
• The supplier has been excluded from Medicare by HHS-OIG;
• The supplier is precluded from billing Medicaid;
• The supplier has been subject to any “final adverse action” in the last 10 years;
• The supplier has been excluded from any federal healthcare program; or
• CMS has lifted a temporary moratorium for a particular supplier type and a supplier that was prevented from enrolling due to the moratorium applies for enrollment within 6 months from the date the moratorium was lifted.

In addition to all of the above, the certification standards have also be tightened

• All DMEPOS suppliers must obtain oxygen for state-licensed suppliers, where required
• All DMEPOS suppliers must maintain ordering and referring documentation for 7 years of the date of service
• All DMEPOS suppliers are prohibited for sharing a practice location with any other medicare suppler or provider except in the the case of Medicare Part A providers or where a medical provider furnished the items to his or her own patients.
• All DMEPOS suppliers must be open at least 30 hours per week.

All of these restrictions and new provider enrollment procedures are designed to stop what is seen to be the egregious level of abuse encountered within the industry. While these problems do surely exist, the net result will be a substantial increase in the complexity associated with future Medicare authorization for both the good and the bad. These complexities will add significant time and cost to the process. DMEPOS suppliers and those responsible for their enrollment activities should take note and plan accordingly.