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CMS will hold a National Provider Call to discuss the revalidation of Medicare provider enrollment information on Thursday, October 27th, 2011; from 12:30 – 2PM Eastern. Most providers and suppliers who are enrolled in the Medicare program will have to revalidate their enrollment which will be reviewed under the new risk screening criteria required by the Affordable Care Act Section 6401(a). Learn what you can expect and how to prepare for this process.

Target Audience: All providers and suppliers enrolled with Medicare prior to March 25, 2011 and who expect to receive payment from Medicare for services provided!!!!!! (I had to add those exclamation points – what a statement – if you expect to be paid, you need to revalidate.)

The agenda will include:

1. What is Revalidation?
2. ACA Screening Requirements
3. Electronic Funds Transfer
4. Streamlining the Process
5. Phased Revalidation
6. Tips on Revalidation
7. Question and Answer Session (my favorite!)

Registration Information: In order to receive the call-in information, you must register for the call. Registration will close at 12pm on Thursday, October 27, 2011 or when available space has been filled; no exceptions will be made, so please register early. For more details, including instructions on registering for the call, click here. The audio recording and written transcript will be posted after the call.

Presentation: The presentation will be posted at least one day before the call in the Downloads section of the page here.

For more information about provider enrollment revalidation, review the Medicare Learning Networks publication here.

Announcement from CMS:

All providers and suppliers who enrolled in the Medicare program prior to Friday, March 25, 2011, will be required to revalidate their enrollment under new risk screening criteria required by the Affordable Care Act (section 6401a). Providers/suppliers who enrolled on or after Friday, March 25, 2011 have already been subject to this screening, and need not revalidate at this time.

New Screening Criteria

In the continued effort to reduce fraud, waste, and abuse, CMS implemented new screening criteria to the Medicare provider/supplier enrollment process beginning in March 2011. Newly-enrolling and revalidating providers and suppliers are placed in one of three screening categories limited, moderate, or high each representing the level of risk to the Medicare program for the particular category of provider/supplier, and determining the degree of screening to be performed by the Medicare Administrative Contractor (MAC) processing the enrollment application. More information on the screening categories is here.

Notices Will Be Sent to Providers/Suppliers

Between now and March 2013, MACs will be sending notices to individual providers/suppliers; please begin the revalidation process as soon as you hear from your MAC. Upon receipt of the revalidation request, providers and suppliers have 60 days from the date of the letter to submit complete enrollment forms. Failure to submit the enrollment forms as requested may result in the deactivation of your Medicare billing privileges. The easiest and quickest way to revalidate your enrollment information is by using Internet-based PECOS (Provider Enrollment, Chain, and Ownership System), at https://pecos.CMS.hhs.gov.

Fees Levied

Section 6401a of the Affordable Care Act requires institutional providers and suppliers to pay an application fee when enrolling or revalidating (institutional provider includes any provider or supplier that submits a paper Medicare enrollment application using the CMS-855A; CMS-855B, not including physician and non-physician practitioner organizations; CMS-855S; or associated Internet-based PECOS enrollment applications); these fees may be paid via www.Pay.gov.

In order to reduce the burden on the provider, CMS is working to develop innovative technologies and streamlined enrollment processes including Internet-based PECOS. Updates will continue to be shared with the provider community as these efforts progress.

For more information about provider revalidation, review the Medicare Learning Networks Special Edition Article #SE1126, titled Further Details on the Revalidation of Provider Enrollment Information.

First the facts on what has taken place so far in the 2011 EHR Incentive Programs.

• As of June 30th, the total of Medicare EHR Incentive Program payments is over $94 million.
• As of June 30th, over $166 million has been paid in Medicaid EHR incentives since the program began in January. In May and June, four states launched Medicaid EHRIncentive Programs – Indiana, Ohio, Pennsylvania, and Washington, bringing the total states with Medicaid EHR Incentive Programs to 21. More states will launch in July.
• There are 68,001 active registrations of eligible professionals and eligible hospitals for the Medicare and Medicaid EHR Incentive Programs.

If your group hasn’t received a check and hasn’t registered for the Medicare or Medicaid Incentive Program, then this blog post is for you! For anyone who is really just beginning their EHR journey, today’s presentation clarified previous information given by CMS, as well as giving listeners new information about the programs.

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The Centers for Medicare & Medicaid Services (CMS) has the continuing goal of reducing fraud, waste, and abuse through all available avenues. The Affordable Care Act requires CMS to determine the level of screening to be conducted during provider and supplier enrollment based on the level of risk posed to the Medicare system. With the enactment of the Affordable Care Act, CMS has the increased ability to focus efforts on prevention, rather than simply acting after the fact. The use of risk categories and associated screening levels will help ensure that only legitimate providers and suppliers are enrolled in Medicare, Medicaid, and CHIP, and that only legitimate claims are paid.

Effective Friday, March 25, 2011, newly-enrolling and revalidating providers and suppliers will be placed in one of three screening categories limited, moderate, or high. These categories represent the level of risk for fraud, waste, and abuse to the Medicare program for the particular category of provider/supplier, and determine the degree of screening to be performed by the Medicare Administrative Contractor (MAC) processing the enrollment application.

Providers/suppliers in the limited screening category will include:

o Physicians

o Non-physician practitioners other than physical therapists

o Medical groups or clinics

o Ambulatory surgical centers

o Competitive Acquisition Program / Part B Vendors

o End-Stage Renal Disease facilities

o Federally-Qualified Health Centers

o Histocompatibility laboratories

o Hospitals (including Critical Access Hospitals, Department of Veterans Affairs hospitals, and other federally-owned hospital facilities)

o Health programs operated by an Indian Health Program (as defined in section 4(12) of the Indian Health Care Improvement Act) or an urban Indian organization (as defined in section 4(29) of the Indian Health Care Improvement Act) that receives funding from the Indian Health Service pursuant to Title V of the Indian Health Care Improvement Act

o Mammography screening centers

o Mass immunization roster billers

o Organ procurement organizations

o Pharmacies that are newly enrolling or revalidating via the CMS-855B application

o Radiation Therapy Centers

o Religious non-medical health care institutions

o Rural Health Clinics

o Skilled Nursing Facilities

Providers in the moderate screening category will include:

o Ambulance service suppliers

o Community Mental Health Centers (CMHCs)

o Comprehensive Outpatient Rehabilitation Facilities (CORFs)

o Hospice organizations

o Independent clinical laboratories

o Independent Diagnostic Testing Facilities (IDTFs)

o Physical therapists enrolling as individuals or as group practices

o Portable x-ray suppliers (PXRS)

o Revalidating Home Health Agencies (HHAs)

o Revalidating DMEPOS suppliers

Providers in the high screening category will include:

o Newly-enrolling DMEPOS suppliers

o Newly-enrolling Home Health Agencies (HHAs)

o Providers and suppliers reassigned from the limited or moderate categories due to triggering events.

Triggering events include the following instances:

• imposition of a payment suspension within the previous 10 years;
• a provider or supplier has been terminated or is otherwise precluded from billing Medicaid;
• exclusion by the OIG;
• a provider or supplier has had billing privileges revoked by a Medicare contractor within the previous 10 years and such provider/supplier is attempting to establish additional Medicare billing privileges by enrolling as a new provider or supplier or establish billing privileges for a new practice location;
• a provider or supplier has been excluded from any federal health care program;
• a provider or supplier has been subject to any final adverse action (as defined in 42 CFR 424.502) within the past 10 years; or
• instances in which CMS lifts a temporary moratorium for a particular provider or supplier type and a provider or supplier that was prevented from enrolling based on the moratorium, applies for enrollment as a Medicare provider or supplier at any time within 6 months from the date the moratorium was lifted.

The enrollment screening procedures will vary depending upon the categories described above. Screening procedures for the limited screening category will largely be the same as those currently in use; screening procedures for the moderate screening category will include all current screening measures, as well as a site visit; screening procedures for the high screening category will include all current screening measures, as well as a site visit and, at a future date a fingerprint-based criminal background check.

CMS will continuously evaluate whether a change of the assignment of categories of providers and suppliers to the various risk categories is necessary. If CMS assigns certain groups of providers and/or suppliers to a different category, this change will be proposed in the Federal Register. However, CMS will not publish a notice or a proposed rule in the Federal Register that would include instances in which an individual provider/supplier is reassigned based upon meeting one or more of the triggering events.

NOTE April 2011: CMS recently announced that July 5, 2011 will not be the date that claim editing will begin.

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If you read my post on November 29th, you already know that CMS delayed pulling the trigger on January 1, 2011 to require PECOS enrollment for ordering and referring providers and enforcing nonpayment of claims that fail the ordering/referring provider edits.

CMS has just announced a new implementation date (calling it “a placeholder future implementation”) of July 5, 2011 – unknown.

As a refresher, the only providers who can order/refer Medicare beneficiary services are:

doctor of medicine or osteopathy;
dental medicine;
dental surgery;
podiatric medicine;
optometry;
chiropractic medicine;
physician assistant;
certified clinical nurse specialist;
nurse practitioner;
clinical psychologist;
certified nurse midwife;
clinical social worker

Claims that are the result of an order or a referral must contain the National Provider Identifier (NPI) and the name of the ordering/referring provider and the ordering/referring provider must be in PECOS or in the Medicare carriers or Part B MACs claims system with one of the above types/specialties.

The claim editing that will begin on July 5, 2011 date not known will verify the ordering/referring provider on a claim is eligible to order/refer and is enrolled in Medicare.

The process to be used to determine if the ordering/referring provider on the claim matches the provider in the national PECOS file or in the contractors master provider file is as follows:

• MCS (Multi-Carrier System) will verify the National Provider Identifier (NPI) of the ordering/referring provider reported on the claim against the national PECOS file.
• If a match is not found, the MCS will verify the NPI of the ordering/referring provider on the claim against the MCS master provider file.
• If a match is found, the MCS will then compare the first letter of the first name and the first 4 letters of the last name of the matched record.
• If the names match, the ordering/referring provider on the claim is considered verified.

If you’ve not verified that your providers are properly enrolled in PECOS, you have yet another chance to get it figured out.

Here’s the Cheat Sheet:

1. Check to see if your provider is enrolled by reviewing the Ordering and Referring file found in the download section of the OrderingReferringReport tab (click here) on the Medicare Provider and Supplier Web Site. The report is currently more than 15,000 pages but you can view it on the screen.
2. If not enrolled, you can get your provider enrolled by paper or electronically. The Internet-based PECOS application is here.
3. After submitting an enrollment application via Internet-based PECOS, you must:
   • Print, sign and date (blue ink recommend) the Certification Statement(s), and
   • Mail the Certification Statement(s) and applicable supporting documentation to the designated Medicare contractor (no later than 7 days after you complete the online portion.)

   NOTE: The Medicare contractor will not be able to begin to process your enrollment application until it receives a signed and dated Certification Statement.

For more detailed information on PECOS, click on the PECOS category on the right-hand side of this web page.

NOTE: The date has been changed to July 5, 2011 delayed indefinitely.

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The following statement was released by CMS on November 26, 2010:

The Centers for Medicare & Medicaid Services (CMS) previously announced that, beginning January 3, 2011, if certain Part B billed items and services require an ordering/referring provider and the ordering/referring provider is not in the claim, is not of a profession that is permitted to order/refer, or does not have an enrollment record in the Medicare Provider Enrollment, Chain and Ownership System (PECOS), the claim will not be paid. The automated edits will not be turned on effective January 3, 2011. We are working diligently to resolve enrollment backlogs and other system issues and will provide ample advanced notice to the provider and beneficiary communities before we begin any automatic nonpayment actions.

Previous posts on enrolling physicians in PECOS are here and here.

Image by Squash713 via Flickr

NOTE: The date has been changed to July 5, 2011 has been delayed indefinitely.

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Many managers have told me they know their providers are in PECOS but they’re not on the list OR they never enrolled their providers but they are on the list OR they’ve sent their paperwork and have not heard back for 2, 4, 6 weeks – should they be worried? The CMS website says “It is possible that it could take 45-60 days, sometimes longer, for Medicare enrollment contractors to process enrollment applications,” so I guess we all need to chill out a little.

The massive undertaking of qualifying every single healthcare professional who refers/orders or provides medical services to Medicare patients in order to sift out those who would lie about providing goods and services is fraught with confusion, miscommunication and misunderstanding. That’s okay, though, because CMS says no checks for services or goods will be withheld due to providers not being listed in PECOS, at this time. They know it’s a mess and it will take quite a while to get everyone straightened out, on the list and able to get checks from CMS if and only if their name is on the list.

Below is the CMS fact sheet published last week.

Image via Wikipedia

Medicare Enrollment Guidance for Physicians that Infrequently Receive Reimbursement from the Medicare Program

Traditionally, most physicians have enrolled in the Medicare program to furnish covered services to Medicare beneficiaries. However, with the implementation of Section 6405 of the Affordable Care Act, some physicians will need to enroll in the Medicare program for the sole purpose of certifying or ordering services for Medicare beneficiaries. These physicians do not send claims to a Medicare contractor for the services they furnish.

In the process of implementing the provisions contained in the Affordable Care Act, we have become aware of several unique enrollment issues for certain types of physicians or practitioners. Specifically, we have modified the process of enrollment to accommodate the special circumstances of the following individual physicians and practitioners:

• Physicians employed by the Department of Veterans Affairs
• Physicians employed by the Public Health Service
• Physicians employed by the Department of Defense Tricare program
• Physicians employed by Federally Qualified Health Centers (FQHCs), Rural Health Clinics (RHCs) or Critical Access Hospitals (CAHs)
• Physicians in a Fellowship
• Dentists, including oral surgeons

This document provides guidance to those practitioners.

Q: How can I verify whether I am already enrolled in PECOS?

A: If a physician is concerned or uncertain about whether s/he is actually enrolled in the Provider Enrollment, Chain and Ownership System (PECOS), s/he can review the Ordering and Referring file found in the download section of the “OrderingReferringReport tab (click here) on the Medicare Provider and Supplier Web Site.

Providers and suppliers can check with the ordering or referring physician to see if the physician is currently seeing Medicare patients and the physicians claims are being paid. Until we advise otherwise, your orders and referrals will not be rejected due to the lack of an approved enrollment record in PECOS.

Q: I am a physician employed by the Department of Veterans Affairs, Department of Defense Tricare program, by the Public Health Service, an FQHC, an RHC, or a CAH. Do I need to enroll in PECOS to order and refer items or services for Medicare beneficiaries?

A: Yes, but we have abbreviated the enrollment process and documents for physicians employed by the Department of Veterans Affairs, the Public Health Service, the Department of Defense Tricare program, an FQHC, an RHC, or a CAH. However, because this is a unique solution to enrollment for a specific set of physicians, our systems will not accommodate the abbreviated forms on-line. Therefore, any physician employed by the Department of Veterans Affairs, the Public Health Service, the Department of Defense Tricare program, an FQHC, an RHC, or a CAH, who is not already enrolled in PECOS, must use the paper enrollment application process
and do the following:

Complete the following sections of the paper CMS-855I, Medicare Enrollment Application for Physicians and Non-Physician Practitioners and mail the completed form to the designated Medicare enrollment contractor:

• Section 1 Basic Information (they would be a new enrollee)
• Section 2 Identifying Information (section 2A, 2B, 2D and if appropriate 2H and 2K)
• Section 3 Final Adverse Actions/Convictions
• Section 4C/4E Practice Location Information (same as section 2B)
• Section 13 Contact Person
• Section 15 Certification Statement (must be signed and datedblue ink recommended)
• Section 17 Supporting Documentation (cover letter stating the provider is only enrolling to order and refer services to a beneficiary)

Note: Physicians who are employed by the Department of Veterans Affairs, the Public Health Service, the Department of Defense Tricare program, an RHC, FQHC, or CAH are not required to include the Electronic Funds Authorization Agreement (CMS-588) or the Medicare Physician and Supplier Agreement (CMS-460) with the enrollment form.

Q: I am a physician in a fellowship program. Do I need to enroll in PECOS?

A: If you are a physician in a fellowship, and licensed in the State, you can enroll in Medicare for the sole purpose of ordering or referring items or services for Medicare beneficiaries. To enroll as a referring and ordering physician-only you would need to complete the abbreviated enrollment application form in the same way as other physicians (VA, DoD, PHS, FQHC, RHC CAH) who are enrolling to order and refer only (see previous question.) If you elect to enroll to order and refer only, you would not be enrolled in Medicare for the purpose of providing Medicare services to Medicare beneficiaries. In order to provide covered services to Medicare beneficiaries, a physician would need to complete the full enrollment application either on-line or in hard copy.

Q: I am an Oral Surgeon or Dentist. How do I Enroll in PECOS?

A: Dentists, including oral surgeons, must enroll in the Medicare program to receive reimbursement for services furnished to Medicare beneficiaries or to order covered items or services for Medicare beneficiaries. Oral surgeons would complete the same paper forms, or on-line application, as any other practitioner enrolling in PECOS.
If you elect to enroll as a referring and ordering physician-only, you would need to complete the abbreviated enrollment application form in the same way as other physicians (VA, DoD, PHS, FQHC, RHC CAH) who are enrolling to order and refer only (see previous two questions.) If you elect to enroll to order and refer only, you would not be enrolled in Medicare for the purpose of providing Medicare services to Medicare beneficiaries.

In order to provide covered services to Medicare beneficiaries, a dentist, including oral surgeons, would need to complete the full enrollment application either on-line or in hard copy.

Note: In completing the enrollment application portion dealing with specialty, oral surgeons would check the oral surgery (dentist only) box found in section 2 of the Medicare enrollment application and any other dentist would check the box titled, Undefined Physician Type and specify that they are a dentist in the space provided. In the near future, we will revise the Medicare enrollment application to add Dentist as a physician specialty.

Internet-based PECOS

Physicians and practitioners who are employed by the Department of Veterans Affairs, the Defense Department, the Public Health Service, an RHC, FQHC, or CAH must complete the paper enrollment application that has been modified and shortened to accommodate the special situation of these professionals. All other physicians and practitioners who furnish services to Medicare beneficiaries must enroll in the Medicare program to receive reimbursement and order/refer in the Medicare program. For those physicians and practitioners using the on-line process, we have developed a document that will help you through the PECOS enrollment process. It will be easier to complete the process if you review this document before you begin the enrollment process.

• The document titled, Internet-based PECOS — Getting Started Guide for Physicians and Non-Physician Practitioners can be found here.

• Although you are permitted to complete your enrollment application in hard copy, it will be easier and quicker if you use the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) to complete the Medicare enrollment process. The Internet-based PECOS application is completed via the web here.
• After submitting an enrollment application via Internet-based PECOS, you must:
  • Print, sign and date (blue ink recommend) the Certification Statement(s), and
  • Mail the Certification Statement(s) and applicable supporting documentation to the designated Medicare contractor (no later than 7 days after you complete the online portion.)
  • NOTE: The Medicare contractor will not be able to begin to process your enrollment application until it receives a signed and dated Certification Statement.

Additional Medicare Enrollment Information

To ask a provider enrollment question, contact the Medicare contractor for your State. Medicare provider enrollment contact information for each State can be found here.

To report Internet-based PECOS navigation, access, or printing problem with Internet-based PECOS, contact the EUS Help Desk at 1-866-484-8049 or send an e-mail to the EUS Help Desk to EUSSupport@cgi.com

For additional information regarding the Medicare enrollment process, visit the website here. Of course, if you have any additional questions about the Medicare enrollment process, you can contact the designated Medicare contractor for your state.

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If you haven’t started yet but plan to use the online process to enroll your providers or yourself, here’s a really excellent SlideShare presentation by David Zetter that steps you through the enrollment process by showing screen shots of each step. You can contact David Zetter here.