institute on medicare and medicaid payment issues ... · institute on medicare and medicaid payment...

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Institute on Medicare and Medicaid Payment Issues

Fundamentals of Provider Enrollment

Emily W.G. Towey and Jeanne L. Vance

Fundamentals of Provider Enrollment Federal Program

Integrity Initiatives

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Strengthening provider enrollment standards and procedures.

2. Improving prepayment review of claims.

3. Focusing postpayment claims review on most vulnerable areas.

4. Improving oversight of contractors.

5. Developing a robust process for addressing identified vulnerabilities.

GAO Findings

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Source: Medicare and Medicaid Fraud, Waste, and Abuse: Effective Implementation of Recent Laws and Agency Actions Could HelpReduce Improper Payments GAO-11-409T March 9, 2011

Fundamentals of Provider Enrollment Medicare Provider Enrollment

Process by which providers become authorized to bill the Medicare program

Provides a means for CMS to screen providers

Medicare Enrollment Resources:See 42 CFR §420.200 et seq.; see also 42 CFR §424.500 et seq.; CMS Program Integrity Manual – Chapters 10 and 15; CMS State Operations Manual – Chapter 23.

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Fundamentals of Provider Enrollment CMS Enrollment Forms

855A — Part A ProvidersHospitals, home health agencies, skilled nursing facilities, FQHCs, ESRD

855B — Part B ProvidersASCs, clinics/group practices, hospitals billing physician services,

competitive acquisition program Part B drug vendors, IDTFs, pharmacies

855I — Physicians and Non-Physician Practitioners

855R — Reassignment of Medicare BenefitsUsed to “link” physician to another supplier (e.g., a medical group, an IDTF, a hospital billing Part B services)

855S — DME Suppliers(Beware also of separate competitive bidding process)

855O — Ordering and Referring Physicians and Non-Physician Practitioners

CMS 588 — Electronic Funds Transfer Authorization Agreement

CMS 460 — Participating Provider Agreement

Fundamentals of Provider Enrollment What is so hard about filling out forms?

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Types of Enrollment Actions

Fundamentals of Provider Enrollment Types of Enrollment Actions

New enrollments

Revalidations

Changes of information

Change of ownership, mergers and consolidations

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Fundamentals of Provider Enrollment 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

42 C.F.R. § 424.520(d); 42 C.F.R. § 489.13(b); CMS State Operations Manual Chapter 2 § 2008D

Fundamentals of Provider Enrollment Medicare Revalidation

Two Types

1. Cyclical (every three to five years)

2. Off-Cycle

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Fundamentals of Provider Enrollment Revalidation Post-PPACA –

The CMS Revalidation Effort

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.

Fundamentals of Provider Enrollment Consequences of Ignoring a

Revalidation Request

1. Deactivation – provider/supplier can apply to reactivate

2. Revocation – provider/supplier may not reapply until the period of the enrollment ban passes (one to three years)

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Fundamentals of Provider Enrollment New Enrollment Forms

Changed in July of 2011

Now Required

1. The exact date that ownership or control began for direct or indirect owners, officers, directors, managing employees and lienholders

2. The exact percentage of ownership or control

3. The date and place of birth of officers, directors, managing employees, and direct and indirect owners

4. Identities of all physician owners of physician-owned hospitals

Fundamentals of Provider Enrollment Revalidation Practice Tips

1. Keep the envelope for the revalidation request.

2. Consider affirmatively revalidating if you are reporting changes anyway.

3. Check the CMS revalidation list at: http://www.cms.gov/MedicareProviderSupEnroll/11_Revalidations.asp#TopOfPage

4. 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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Fundamentals of Provider Enrollment Revalidation Practice Tips

5. Keep copies of the revalidation applications; keep proof of delivery with the date of delivery.

6. Pre-enroll to submit the revalidation application electronically in the Provider Enrollment, Chain and Ownership System, if desired.

7. Review revalidation requests by provider transaction access number; many entities will have more than one PTAN and will need to revalidate each one.

8. Assemble your revalidation application(s) in advance.

Fundamentals of Provider Enrollment Changes of Information

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Provider Type 30-day Reporting 90-dayReporting

DMEPOS Suppliers All Changes N/A

IDTFs Change of ownership, location, general supervision, adverse legal actions

All other changes

Physicians, Nonphysicianpractitioners, physician organizations

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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Fundamentals of Provider Enrollment 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

Fundamentals of Provider Enrollment 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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Fundamentals of Provider Enrollment Mergers and Consolidations

The collapse of two or more enrollments into one

Fundamentals of Provider Enrollment Special Rule

Home 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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Fundamentals of Provider Enrollment 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.

Fundamentals of Provider Enrollment When to File

Initial Enrollments – up to 30 days prior to the date that 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.

CMS Program Integrity Manual, Chapter 15 § 15.8.1; 42 C.F.R. § 424.516(e)

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Interesting Portions of the

855 Forms

Fundamentals of Provider Enrollment Interesting Portions of the Forms

What are reportable adverse actions? (Section 3)

Real Life Question:

Plain Jane ASC Developer calls and wants to know whether she can terminate a development contract with a person who is to be a co-investor and the administrator of their surgery center because the person failed to disclose to Jane that he is a registered sex offender. Would this information preclude enrollment of the ASC in the Medicare program, to possibly permit a claim of fraud?

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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. § 13a-3; 42 U.S.C. § 1320a-7


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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Web-based vs. Paper Enrollment

Applications

Fundamentals of Provider Enrollment PECOS

CMS’ web-based enrollment system: the Provider Enrollment, Chain and Organization System (“PECOS”)

PECOS gives providers and suppliers better control and understanding of their Medicare enrollment information.

The system is still under development; recent enhancements have made it more user-friendly, but it still has limitations.

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Initial enrollment applications for federally qualified health centers, rural health clinics, and end-stage renal disease facilities

Change of Ownership (“CHOW”)

Mergers, acquisitions, and consolidations

Part A providers enrolling to bill for Part B services

PAPER ONLY

PECOS vs. Paper

Most initial enrollment applications

Change of Information (“CHOI”)

Add or change a reassignment of benefits

Revalidation of enrollment information

Reactivation of an existing enrollment record

Voluntary termination

PECOS OR PAPER

Not all enrollment filings can be accomplished via PECOS:

Fundamentals of Provider Enrollment Advantages of PECOS

Faster Processing

Faster Completion

Electronic File

Better Access to Enrollment Information

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Fundamentals of Provider Enrollment Enhancements to PECOS

Recently-implemented enhancements: E-Signature

“Fast Track” Revalidation

Coming soon, according to CMS: Electronic upload of supporting documents

Batch upload capability

Streamlined processes for group practices

Reassignment reports

Fewer duplicative document submission requirements

Fundamentals of Provider Enrollment 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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Fundamentals of Provider Enrollment New Enrollment Rules Under

Health Reform

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)

Fundamentals of Provider Enrollment Application Fees

$523.00 for CY2012

Only apply to “institutional” providers

Must be paid for: Initial enrollment

Addition of practice location

Revalidation

Limited hardship exception request

Paid through PECOS 34

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Fundamentals of Provider Enrollment Risk Categories

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Limited Risk Providers

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

Ambulance suppliers, community mental health centers, comprehensive outpatient rehabilitation facilities, hospice

organizations, independent diagnostic testing facilities, independent clinical laboratories, physical therapy including

physical therapy groups, portable x-ray suppliers, and currently-enrolled home health agencies.

Source: CMS


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High Risk Providers

Newly-enrolling home health agencies and newly-enrolling suppliers of DMEPOS

Source: CMS

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Screening Procedures

Source: CMS

Fundamentals of Provider Enrollment Moving to a “High”

Risk Category

Exclusions

Payment suspensions

Medicaid terminations

For 6 months after CMS lifts a temporary moratorium

Certain “final adverse actions”

Certain actions involving owners

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Conducted during normal business hours to determine if provider is “operational”

Lack of exterior signage may result in failed site visit

Important to have full address (including correct suite number) in CMS’ enrollment data

Enrollment Site Visits

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All individuals with a 5% or greater direct or indirect ownership interest in the High Risk provider or supplier

National background check and criminal history check using FBI system

Background Checks and Fingerprinting

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May be used when CMS determines a high risk of fraud, waste, or abuse

Can apply to a particular provider/supplier type orgeographic area

Can also be imposed by state Medicaid programs

Imposed in 6-month increments

Temporary Moratoria on Enrollment

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CMS may suspend payments based on a “credible allegation of fraud”

Fraud hotlines

Audits

Whistleblowers

State Medicaid agencies are required to suspend payments if there is a “credible allegation of fraud”

Suspension of Payments

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IRS Documentation Legal Business Name issues Board Member, Officer, and Managing

Employee Personal Information Full (9-digit) zip codes Signatures in wrong ink color Authorized and Delegated Officials Disclosure of Ownership Interests Letter from Bank

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Enrollment Pitfalls


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

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Enrollment Best Practices

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Fundamentals of Provider Enrollment 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?

Fundamentals of Provider Enrollment 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 Problems

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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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IDTF Billing IssueProblem: Denied claims for certain services, no explanation.

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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.)

Board Member BluesProblem: MAC sends development letter requesting personal information about Board members.


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.

The Name GameProblem: MAC sends development letter asking for clarification relating to provider’s name.

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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.

The Never-Ending ApplicationProblem: The MAC has taken over 12 months to process a new enrollment application.


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.

“CHOW” or “CHOI”Problem: Hospital A is “affiliating with” by 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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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.

Caroline Lott Douglas, P.A. v. Centers for Medicare and Medicaid Services, Dec No. CR2406, Civil Remedies Division Departmental Appeals Board DHHS, Aug 3, 2011.

Retroactive Billing

Problem: Medical Group A filed paper 855B application on November 5, 2011 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, 2011. Medical Group A has Medicare claims that will precede the date its billing privileges commenced that are being denied.


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institute on medicare and medicaid payment issues ... · institute on medicare and medicaid payment...

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