1 I NSTITUTE ON M EDICARE AND M EDICAID P AYMENT I SSUES Fundamentals of Provider Enrollment Disclaimer: The content of this presentation does not constitute legal advice. Types of Enrollment Actions When and Where to File Applications Web-based vs. Paper Enrollment Applications Interesting Portions of the 855 Forms Enrollment Rules Under Health Reform Heightened Medicaid Enrollment Screening Processes Enrollment Pitfalls and Best Practices 1
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INSTITUTE ON MEDICARE ANDMEDICAID PAYMENT ISSUES
Fundamentals of Provider Enrollment
Disclaimer: The content of this presentation does not constitute legal advice.
588 — Electronic Funds Transfer Authorization Agreement
460 — Participating Provider Agreement
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What is so hard about filling out forms?
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Initial enrollment
Revalidation
Change of information
Change of ownership, mergers and consolidations
Types of Enrollment Actions5
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Initial Enrollment Dates
Certified Providers — the date that a survey is passed without deficiencies, or the date of submission of an acceptable plan of correction or waiver request for lower level deficiencies
IDTFs, Physicians, PAs, NPs, CRNAs, LCSWs and Groups — the later of the date of filing of the 855 form that is subsequently approved or the date they begin providing services at the new practice location
Applies to providers/suppliers who enrolled prior to March 25, 2011
Letters began going out in Fall of 2011 and will continue into 2015
New content for revalidation this time around
New program integrity rules
New forms
Patient Protection and Affordable Care Act, Section 6401(a); CMS, Further Details on the Revalidation of Provider Enrollment Information, MLN Matters SE1126, Revised August 10 and December 9, 2011, available at https://www.cms.gov/MLNMattersArticles/downloads/SE1126.pdf; CMS, Important Information on Revalidation of Provider Enrollment, email to [email protected] list serve, November 4, 2011.
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Consequences of Ignoring aRevalidation Request
Deactivation – provider/supplier can apply to reactivate
Revocation – provider/supplier may not reapply until the period of the enrollment ban passes (one to three years)
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Enrollment Forms
Now Required
The exact date that ownership or control began for direct or indirect owners, officers, directors, managing employees and lienholders
The exact percentage of ownership (not control)
The date and place of birth of officers, directors, managing employees, and direct and indirect owners
Identities of all physician owners of physician-owned hospitals
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Revalidation Practice Tips
Keep the envelope for the revalidation request.
Consider affirmatively revalidating if you are reporting changes anyway.
Check the CMS revalidation list at: http://www.cms.gov/MedicareProviderSupEnroll/11_Revalidations.asp#TopOfPage
Letters are going to the special payments address, not the correspondence address. Make sure staff are trained to watch for the letters and immediately route it to the appropriate person.
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Revalidation Practice Tips
Keep copies of the revalidation applications; keep proof of delivery with the date of delivery.
Pre-enroll to submit the revalidation application electronically in the Provider Enrollment, Chain and Ownership System (“PECOS”), if desired.
Review revalidation requests by provider transaction access number (“PTAN”); many entities will have more than one PTAN and will need to revalidate each one.
Assemble your revalidation application(s) in advance.
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Changes of Information or "CHOI"
Provider Type 30-day Reporting 90-day Reporting
DMEPOS Suppliers All Changes N/A
IDTFs Change of ownership, location, general supervision, adverse legal actions
Change of ownership, adverse legal actions (e.g., licensurerevocation), change in practice location
All other changes
All other providers/suppliers (hospitals, HHAs, hospices, etc.)
Change of ownership or control (including changes in authorized or delegated officials), revocation/suspension of state or federal license
All other changes
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Changes of Information
Real Life Problem
Physician did not timely report his termination from eligibility to participate in the Illinois Medicaid program. He reported the matter three months after the occurrence, rather than within the 30 days required. DAB upheld the revocation.
Parrish v. CMS, Civil Remedies Division Departmental Appeals Board DHHS Decision No. CR2449, October 12, 2011
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Changes of Ownership or “CHOW”
Transfers of Medicare entitlements resulting from the sale of a business where there is a change in TIN, such as in an asset sale.
Merger of the provider corporation into another corporation
Consolidation of two or more corporations resulting in the creation of a new corporation
“Buyer” must assume ownership of “Seller’s” Medicare provider agreement. See CMS-855A, Page 10; see also 42 C.F.R. §489.18(c)
Pro — The approval process relates back to the effective date of the CHOW (alternative is initial enrollment process)
Con — Buyer assumes liability under the Seller’s provider agreement, including penalties
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What is NOT a CHOW
Transfer of corporate stock or the merger of another corporation into the provider corporation
See 42 C.F.R. § 489.18
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Special RuleHome Health Agencies
No change of ownership process is available to HHAs that experience a “change in majority ownership” (“CMO”) within 36 months following the HHA’s initial enrollment into the Medicare program or within 36 months following the HHA’s most recent CMO.
See 42 C.F.R. § 424.502
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Special Enrollment Issues for IDTFs
Equipment
Supervising and/or interpreting physicians
Technicians and credentials
Changes to ownership, location, general supervision and adverse legal actions within 30 days; all other changes within 90 days.
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When and Where to File Applications
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Initial Enrollment - Up to 60 days prior to the date that the provider is to commence providing services for most providers/ suppliers
Initial Enrollment - Providers submitting 855A, ASCs and portable x-ray suppliers up to 180 days prior to the date the provider is to commence providing services
Change of Ownership – may be filed up to 90 days prior to the CHOW date.
Change of Information – with some exceptions, these can be filed up to 90 days prior to the occurrence.
File with the Medicare Administrative Contractor (MAC) assigned to the provider/supplier’s geographic region/ provider/supplier type
A/B MACs by geographic region
DME MACs
Home Health/Hospice MAC
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Figuring Out the Right MAC;Beware of Transitions
MACs are being consolidated through a competitive bidding process (CMS to reduce A/B MACs from 15 to 10)
Cycle of a transition consists of a contract award, an announcement, a bid protest, an appeal and the announcement of an implementation schedule
See http://www.cms.gov/Medicare/Medicare-Contracting/MedicareContractingReform/index.html
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An Example of a MAC Consolidation/Transition
Jurisdiction E (formerly J1) A/B MAC Contractor for California, Hawaii, Nevada, American Samoa, Guam and Northern Mariana Islands awarded to Noridian on September 20, 2012
Announcement made by CMS; transition to occur early 2013
Two bid protests filed October 2012
January 18, 2013, GAO denies bid protests
February 1, 2013 court appeal filed
“Old” MAC (Palmetto GBA) continues to administer claims for now
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Moral of the Story
It is not always crystal clear where to send the enrollment application. Contact information/websites for CMS and the MACs are not always timely updated. A passing awareness of the MAC consolidation issue as it applies to your jurisdiction will help identify whether you are likely to have an issue or not.
An application sent to the wrong MAC will be rejected.
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Web-based vs. Paper Enrollment Applications
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PECOS
CMS’ web-based enrollment system: the Provider Enrollment, Chain and Organization System .
The system is still under development; recent enhancements have made it more user-friendly, but it still has limitations.
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PECOS vs. Paper
Not all enrollment filings can be accomplished via PECOS:
Most initial enrollment applications
Change of Information Add or change a reassignment of
benefits Revalidation of enrollment
information Reactivation of an existing
enrollment record Voluntary termination Change of Ownership
Initial enrollment applications for federally qualified health centers, rural health clinics, and end-stage renal disease facilities
Mergers, acquisitions, and consolidations
Part A providers enrolling to bill for Part B services
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Advantages of PECOS
Faster Processing
Faster Completion
Electronic File
Better Access to Enrollment Information
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Enhancements to PECOS
Recently-implemented enhancements: New Provider Home Page “My Enrollments” Page “Fast Track” Revalidation Primary and Secondary Reassignment Locations Practice Locations by County Electronic upload of supporting documents Fewer duplicative document submission requirements Reassignment reports Medicare ID reports
Coming soon, according to CMS: Batch upload capability Streamlined processes for group practices ADI Accrediting Information
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Access to PECOS
Individuals
Use NPPES login information
Organizations
Authorized Official (AO) must establish PECOS account
“End Users”
Must establish PECOS account
Must request access from AO to provider or supplier’s enrollment records
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Interesting Portions of the 855 Forms
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What is your “legal business name as reported to the Internal Revenue Service?” (Section 2B1)
Name on file with the IRS
Abbreviation, capitalization, etc. may be different than that on file with your Secretary of State.
Interesting Portions of the Forms
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What are reportable adverse actions? (Section 3)
Real Life QuestionTwo physicians who shared ultimate responsibility for ordering the administration of a general anesthesia drug for a patient experienced a 20-day licensure suspension. The physicians did not report the licensure suspension to CMS. The MAC (Highmark) revoked their enrollments and issued a bar on re-enrollment for one year. Physicians argued that when the 30-day reporting date occurred, their licenses were no longer suspended so they had no obligation to report the suspensions. DAB determined that the revocation was proper and upheld the enrollment ban.
Brown and Obeng v. CMS, Civil Remedies Division Departmental Appeals Board DHHS Decision No. CR2145, June 9, 2010
Interesting Portions of the Forms
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Interesting Portions of the Forms
Who has a 5% direct or indirect interest in the provider? (Section 5)
Real Life Question
Desperate Ambulance Company calls. They have an on-site government visitor who requested to see the purchase agreement for a pending change of ownership. The Seller has financed a portion of the sales price and the loan is secured by the assets of Desperate. The loan balance exceeds 5% of the value of Desperate’s assets. The inspector has indicated that he plans to revoke the enrollment and ban re-enrollment for three years. Is this appropriate?
42 U.S.C. § 1320a-7
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Interesting Portions of the Forms
Who is a managing employee? (Section 6)
Contact Persons (Section 13)
Who are “authorized” and delegated officers? (Sections 15 and 16)
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September 23, 2010 – PROPOSED RULE (75 Fed. Reg. 58204)
May 5, 2010 – INTERIM FINAL RULE(75 Fed. Reg. 24437)
February 2, 2011 – FINAL RULE(76 Fed. Reg. 5862)
Enrollment Rules Under Health Reform
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Application Fees
$532.00 for CY2013
Only apply to “institutional” providers
Must be paid for: Initial enrollment
Addition of practice location
Revalidation
Limited hardship exception request
Paid through PECOS
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RISK Categories
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Limited Risk Providers
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Physician or non-physician practitioners and medical groupsor clinics, with the exception of physical therapists and physical
therapist groups, ambulatory surgical centers, competitive acquisition program/Part B vendors, end-stage renal disease facilities, federally qualified health centers, histocompatibility
laboratories, hospitals (including critical access hospitals), Indian Health Services facilities, mammography screening centers, mass
immunization roster billers, organ procurement organizations, pharmacies newly enrolling or revalidating, radiation therapy
centers, religious non-medical health care institutions, rural health clinics, and skilled nursing facilities.
Source: CMS
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Moderate Risk Providers
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Ambulance suppliers, community mental health centers, comprehensive outpatient rehabilitation facilities, hospice
Federal regulations governing Medicaid enrollment:
42 C.F.R. § 455.410 et seq.
April 1, 2012: States required to submit a State plan amendment to CMS to provide assurance that they will comply with new Medicaid enrollment screening rules
Disclosure of Ownership and Control Individuals and entities with 5% or greater direct or indirect
ownership or control of an enrolling provider must provide the State Medicaid Agency with the following information:
Full name
Social Security Number/Tax ID Number
Date of Birth
“Other Disclosing Entities” under common ownership must also be disclosed on the enrolling entity’s Medicaid application regardless of whether the entity also participates in a federal health program.
Individuals with 5% or more ownership or control of a “moderate” or “high” risk provider may be subject to criminal background checks and fingerprinting.
Revalidation or re-enrollment of Medicaid enrollment applications every 5 years
Site visits
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• I R S D O C U M E N T A T I O N
• L E G A L B U S I N E S S N A M E I S S U E S
• B O A R D M E M B E R , O F F I C E R , A N D M A N A G I N G E M P L O Y E E P E R S O N A L I N F O R M A T I O N
• F U L L ( 9 - D I G I T ) Z I P C O D E S
• S I G N A T U R E S I N W R O N G I N K C O L O R
• A U T H O R I Z E D A N D D E L E G A T E D O F F I C I A L S
• D I S C L O S U R E O F O W N E R S H I P I N T E R E S T S
• L E T T E R F R O M B A N K
Enrollment Pitfalls and Best Practices
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Enrollment Best Practices
Get to know PECOS
Always get the 855 forms from CMS website
Verify that NPPES data matches IRS data and data submitted on 855 form
List multiple contact persons
Submit application fee receipt
Establish your own internal verification procedures
Review the 855 form every 90 days
Keep a copy
Track and shepherd the application through completion
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Out The Door Checklist – Paper Filings
Form version
Address on cover letter/envelope matches source data on date of submission
Application is dated
Signatures are dated
Correct NPI is used
Confirm calculation of postage
Proof of payment of enrollment fee needed?
Moratorium applies?
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Follow Up
Follow up at every step. Correspondence sent by the contractor to you or the provider can be lost. Files can get stuck on a desk. Medical Group Enrollment
Provider submits application to the Medicare Administrative Contractor (“MAC”);
MAC approves the application and sends a letter to the provider; and
Submitter is linked.
Hospital Enrollment Provider submits application to MAC;
MAC recommends approval of 855 to State agency (if survey is needed, it occursprior to a favorable recommendation from the State agency);
State agency forwards transmittal to CMS regional office;
Regional office grants approval and issues tie-in notice to MAC;
MAC enters tie-in “in the system”; and
Submitter is linked.
Only after all of this happens can the provider bill.
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How to SolveCommon and Interesting
Enrollment Problems55
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Ravalidation Request
Issue: Provider has failed to report organizational changes to CMS.
Solution: Go ahead and truthfully report changed information on the revalidation application. CMS has indicated that the purpose of this revalidation effort is to ensure all records are up-to-date and does not “generally” contemplate sanctioning providers for failure to report changes timely unless the failure would have rendered provider to be ineligible for enrollment.
Problem: Provider received a revalidation request from CMS. Provider is concerned that its enrollment file is not up-to-date and that is will be sanctioned for failure to report changes on a timely basis.
IDTF Billing Issue
Issue: All CPT codes billed by the IDTF must be listed on Attachment 2 of the IDTF’s 855B. Codes being billed are not listed on current Attachment 2, therefore, the MAC is rejecting claims for these codes.
Solution: File 855B CHOI to update the CPT codes the IDTF intends to bill.
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Problem: Denied claims for certain services, no explanation.
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Board Member Blues
Issue: Contractor will not process the application without personal information of board members, officers, and managing employees. These individuals do not want to share their personal information, which includes SSN, DOB, and place of birth.
Solution: Educate board members on new Medicare requirements. (Actually an old requirement, just not rigorously enforced until recently.)
Problem: MAC sends development letter requesting personal information about Board members.
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Special Rules for Specialties
Issue: Oncology Physician Group A would like to consolidate with Oncology Physician Group B under Group B’s Tax ID number. Group A wants to separately enroll its practice location and bill using its own PTAN.
Solution: Educate the physician specialty practice group it cannot be assigned multiple PTANs under the same Tax ID number.
Problem: MAC sends development letter requesting that a practice location must be enrolled under the main physician group PTAN
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The Name Game
Issue: The provider’s name reported on the application does not match NPPES data, which in turn does not match IRS records. The MAC must use the name reported to the IRS as the legal business name of the provider.
Solution: Update NPPES data and change the name listed on the application to match the name found on the IRS document (CP575, LTR 147C).
Note: Provider will need login information for NPPES system. Otherwise, the Authorized Official must call to request login information.
Problem: MAC sends development letter asking for clarification relating to provider’s name.
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PECOS H*LL
Problem: Physician submits electronic application in PECOS. There are issues with the online system and the physician is unable to edit the application. The physician tries to resolve the issues several times with PECOS support help desk. Physician is unable to certify the accuracy of the PECOS-filed application and the application is rejected. Issue: What can the physician do to salvage a PECOS application gone
bad?
Solution: OK to try PECOS, but as soon as it get ugly, abandon and submit on paper.
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The Never-Ending Application
Issue: The provider has been holding claims until the application is processed by the MAC. The timely filing deadline (12 months) has passed, and the provider is losing money as a result.
Solution: File a request to the MAC for an exception to the timely filing requirement due to “administrative error.” If approved, it will allow the provider to submit claims that are more than 12 months old.
Request must be based on error or misrepresentation by CMS employee or contractor that caused the delay in ability to file the claims.
Need to have file of documentation to support request.
Search for “timely filing job aid” on Palmetto website.
Problem: The MAC has taken over 12 months to process a new enrollment application.
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CHOW or CHOI
Issue: The change must be reported to Medicare within 30 days. How should Hospital A report this change? Should it complete an 855A CHOW or CHOI?
Solution: In this case, Hospital A should complete a CHOI. A CHOW occurs when a provider sells its assets—including its Medicare provider number (PTAN)—to another entity. Generally, this includes a change in tax identification number. Here, all that has occurred is a change in the provider’s “parent company” or “corporate member,” which would be reported as a change to Section 5 of the 855A.
Problem: Hospital A is “affiliating with” Health System B. Many different terms are used to describe the transaction, including “sale,” “acquisition,” and “merger.” Hospital A is a non-profit corporation, and it is granting Health System B a 100% membership interest in the corporation. The hospital will be operated under the same tax identification number after the transaction.
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Retroactive Billing
Issue: Shouldn’t Medical Group A get an earlier enrollment date because the PECOS system did not work properly?
Solution: There is no help available for Medical Group A. Next time, plan to file the enrollment application as early as permitted and be prepared to file paper immediately if the PECOS system fails. However, it is likely that the medical group will be able to bill for services delivered up to 30 days prior to the approved enrollment date
Douglas v. CMS, Civil Remedies Division Departmental Appeals Board Decision No. CR2406 DHHS, August 3, 2011.
Problem: Medical Group A filed paper 855B application on November 5, 2012 for a medical group enrollment. Medical Group A attempted to file the application three weeks earlier, but the “PECOS” system was not functioning properly. The PECOS “help” desk instructed Medical Group A to file on paper because they could not address the computer glitch. The approval letter states that the enrollment is effective November 6, 2012. Medical Group A has Medicare claims that will precede the date its billing privileges commenced that are being denied.
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Disclaimer: The content of this presentation does not constitute legal advice.
