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.

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.

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.

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:

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 .

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 has initiated a new provider enrollment fee for selected Medicare suppliers. The fee applies to institutional accounts enrolling for the first time, those re-validating an existing position or ones adding a new practice location. Starting on March 25^th 2011, Medicare Administrative Contractors will begin collecting the fees along with a provider’s application. The fee has been set at $505 for the fiscal year 2011. Increases in future years will be based upon inflation, as measured by the Consumer Price Index for Urban areas. These fee adjustments will be effective from January 1^st through December 31^st. The amount of the fee owed will be based upon the date of the application.

This new fee will apply only to institutional providers of medical or other times, services or suppliers submitting their application using forms CMS-855A or CMS-855B. The fee does not apply to physicians, physician organizations or non-physician providers and their organizations. According the CMS, those providers subject to the fee assessment can pay it through www.pay.gov immediately after submitting the CMS-855 application or by paper check submitted along with the application or immediately thereafter. The Medicare Administrative Contractions reviewing the application will not be allowed to proceed without the fee having been paid or an exemption having been granted. The fee is nonrefundable except in the case where a hardship exception has been approved, the application is rejected prior to the beginning of the screening process or the application was denied as a result of the the imposition of a temporary moratorium by the CMS.

Hardship Exemption

To qualify for a hardship exemption the provider must make a strong argument and provide all necessary supporting documentation. For an exemption based upon low profit/capital position, the provider must submit historical costs, recent financial reports or tax returns to substantiate it’s claim. Other positions that may suggest that a hardship exception is warranted include: Heavy bad debt expense, a significant level of financial assistance furnished to patients, being a significant member/partner of an organization that furnishes a disproportionate amount of medical care to low income populations, Whether an institutional provider receives considerable amounts of funding through disproportionate shared hospital payments, whether the provider is enrolling in a declared disaster area.

The CMS has 60 days to approve/disapprove a hardship exemption. If the request was turned down and the provider has not yet submitted the fee it has 30 days to do so. If the provider wishes to appeal the CMS decision, it may file a written request to reconsider with the CMS within 60 days of receipt of the initial decision notification.

The CMS considers the $505 fee to be well within the abilities of any well funded institutional provider enrolling in Medicare. The burden of proof is likely to be high and it will be the provider responsibility to make make it’s case, employing strong logic along with substantial supporting evidence. At the end of the day, unless it’s are real hardship for your organization, the best course of action is to go ahead and pay the fee thereby likely saving yourself an extra 60 days in the provider enrollment process. To learn complete details check here.

As of March 25, 2011 the new CMS provider enrollment rules are enacted.  We covered most of the proposed changes in a previous blog post so we’ll just briefly touch on them here.  The primary objective of these changes is to address and help minimize the incidents of  fraud and abuse in the Medicare program.  The new processes includes additional screening,  the suspension of payments where allegations of fraud exist and the new rules grant the CMS the authority to impose a temporary moratorium on new enrollments for particular types of practices in particular geographic areas. There are also new application fees and procedures included as part of the rules revamp.

The new screening process includes assigning providers and suppliers to one of three risk levels: limited, moderate or high.  The screening process will be more detailed and involved the higher the assigned risk category.

Non-refundable Application fees will be charged when initially enrolling in Medicare, when adding a practice location or when revalidating enrollment information.  The fee for March 25, 2011 until Dec 31, 2100 is $505. There are hardship exceptions and refunds are possible if an application is rejected during screening or a temporary moratorium has been applied.

CMS is given the right to impose a moratorium on the enrollment of new Medicare providers of a particular type in a particular geographic areas and the establishment of new practice locations of those types in said locations.  This moratorium would be in response to a high incident of fraud and abuse allegations.

As a practical matter these procedurally changes are likely to have little effect on the typical provider enrollment process.  Where they do come into play it will make the enrollment process considerably more complicated and involved.

The detailed instructions can be found here

The Health and Human Services Department along with the Justice Department have issued rules detailing several new provider enrollment procedural steps and investigative routines to help identify and prevent fraud in the Medicare, Medicaid and the Children Health Insurance Program, a key provision of the healthcare law enacted last year. The rules are designed to help these agencies act in a more proactive way to prevent and target potential improper payments. The rules are out and open for comment for the next 60 days. They can be found here

The goal of these new rules are to move those suspected of fraud off the approved vendor list more quickly and tighten the provider enrollment process to prevent high risk providers from getting approved in the first place. In addition to the rule changes, the program incorporates both improved investigative technologies and an increases in manpower.

Individual providers, geographic areas and provider specialties will be evaluate. Based upon historical trends and the level of known or suspected fraudulent activities, they will be assigned a specific risk assessment level of “Limited”, “Moderate” or “High”. Based upon that classification, a providers will undergo the following screening process as part of their enrollment process.

Proposed Screening Levels and Procedures for Medicare Physicians,Non-Physician Practitioners, Providers, and Suppliers

The major changes to the existing screening process is the addition of unscheduled site visits, criminal background checks and fingerprinting for those providers deemed to be in the Moderate or High risk categories. The vast majority of providers will of course fall within the Limited category and will see no changes to their existing provider enrollment process. State run Medicaid and CHIP programs will be encouraged to adopt the same or similar procedures.

Listen to details of the announcement click below

Anti Fraud Program Announcement