April 13, 2009

(But according to http://www.cms.hhs.gov/MedicareProviderSupEnroll, the site will be down for system modifications between April 16 and April 20….)

If you enjoy preparing and filing your income tax returns, you are going to have a field day enrolling in Medicare. Changes in the enrollment system over the last few years have made the process very complex. Transitions from carriers to Medicare Administrative Contractors (MACs) did nothing to simplify matters. Whether the introduction of the internet-based Provider Enrollment, Chain and Ownership System (PECOS), https://pecos.cms.hhs.gov on April 1st makes keeping one’s enrollment information up to date any easier remains to be seen.

Every physician or other practitioner who submits claims to Medicare must enroll in the program by filing a CMS-855I form, and an 855R is you are reassigning your benefits to another entity such as a group practice. Group practices must enroll in the Medicare program separately, using the CMS-855B application form You should enroll initially when you begin furnishing services to Medicare beneficiaries. If you change location or practice ownership, you must notify the relevant Medicare contractor within 30 days. Adverse legal action such as a physician’s being debarred or excluded by any Federal or State health care program, having his or her medical license suspended or revoked by a State licensing authority or his or her Medicare billing privileges revoked by a Medicare contractor, or has a revocation or suspension by an accreditation organization, must also be reported within 30 days.

Other changes are likewise reportable as soon as possible, but no later than 90 days after the triggering event, which occurs when:

1. The physician changes his or her business structure (e.g., sole proprietorship to sole incorporated owner or vice versa); or
2. As a business owner, the physician changes the organization’s legal business name and/or Taxpayer Identification Number with the Internal Revenue Service; or
3. The physician retires or stops seeing Medicare patients.

If you enrolled with Medicare before 2003 and have not updated your enrollment information since that time, you will need to complete the entire CMS-855 application or PECOS application in order to make any changes. If, for example, the practice employs a new physician, the practice’s owners will have to complete a new CMS-855B for the practice before they can enroll the individual physician and reassign his/her benefits to the group.

Even if you are not changing any enrollment information, you may be completing new CMS-855 forms as part of the carrier “revalidation efforts” that CMS recently ordered carriers to launch if there are funds available at the end of the fiscal year. CMS is strongly encouraging physicians and practices to resubmit their enrollment application if more than five years have passed since the last application. The new PECOS option may prove valuable in the timely completion of enrollment or re-enrollment, since it entails an audit function ensuring that all required information is provided, eliminates data-entry errors made by CMS contractors, and otherwise attempts to expedite the process. It is important to note that the contractor must still receive a signed certification statement and any attachments by mail, however.

The timely completion of an acceptable application became much more important that it had been in the past when the 2009 changes to the Medicare Physician Fee Schedule went into effect. Previously, you could be paid for services provided as much as 27 month before you were enrolled in Medicare. As of January 1, 2009, Medicare will not pay for services furnished more than 30 days before your “billing effective date.” Your billing effective date is the later of:

1. The date you filed an application that your Medicare contractor ultimately approves, or
2. The date you first provided Medicare services at a new practice location.

In an extremely helpful manual jointly issued by the American Medical Association and the Medical Group Management Association entitled “The Medicare Provider Enrollment Toolkit, the AMA and MGMA described six scenarios to illustrate the effective date of an application organization. The manual also contains checklists of the documentation one will need to fill out a PECOS application as well as of common omissions, and it describes the appeals and correction process in detail. MGMA and AMA members only are able to download the manual from www.mgma.com or www.ama-assn.org, respectively .

One of a number of important changes that the AMA and MGMA (among other physician organizations) persuaded CMS to make was to allow physicians to delegate the process of submitting their online Medicare provider applications to staff or to an agent, e.g., a billing company. Originally CMS intended to limit access to PECOS to the individual physician.

We at ABC are grateful for this sensible decision that enables us to assist clients with the cumbersome task of keeping their Medicare enrollments current. The AMA-MGMA manual is very helpful to us, and we commend it to all readers.  As always, we are happy to work with you to answer all your questions. If there are particular subjects that you would like us to review in future Alerts, we hope that you will let us know.