Anesthesia Providers: Plan to Revalidate Your Medicare Enrollment When Your Carrier Asks

Anesthesiologists, nurse anesthetists and anesthesiologist assistants who last validated their enrollment in Medicare prior to March 25, 2011 are going to have to revalidate again by March 23, 2013. 

The revalidation is required under Section 6028 of the Affordable Care Act.  According to this statutory provision, all providers and suppliers who were initially enrolled before March 25, 2011 and have not revalidated since then must revalidate their enrollment information within 60 days of receiving notice from their carriers, but no later than March 23, 2013.

This is a hassle for physicians and allied health professionals who enrolled or revalidated as Medicare providers in 2009, 2010 or up until March 22nd of this year.  Normally, providers have five years to revalidate.   It may be of modest consolation that the burden will be considerably greater for institutional providers and especially for suppliers.  That is because the revalidation is intended to combat Medicare fraud, by bringing all providers within a new tiered screening process.

Under this new process, physicians and non-physician practitioners other than physical therapists are in the lowest tier and are classified as “limited” risk.  They  are therefore not subject to any additional screening (which raises the question, then why make physicians revalidate early?  The answer is beyond the scope of this Alert).

The second and third tiers consist of providers who pose a “moderate“ or “high” risk of fraud, such as physical therapists, ambulance service suppliers, hospice organizations, independent clinical laboratories, durable medical equipment (DME) providers and home health agencies.  When they apply to enroll, change their information, revalidate or add new locations, these providers must pay a $505 fee and will be subject to one or multiple site visits.  The site visits will determine whether the facility is open; personnel are present; customers are on site (if applicable to that provider or supplier type), and the facility appears to be operational.  Further, under the regulations providers and suppliers in the “high” level of categorical screening are subject to a fingerprint-based criminal background check (but this requirement is not yet being implemented).

The site visits seem not just reasonable but necessary when we consider the types of Medicare fraud routinely committed by some suppliers.  For example, the Department of Justice, the FBI, HHS and the Louisiana State Attorney General's Office issued a joint press release on August 17 announcing that:

The owner of a Baton Rouge, La., durable medical equipment (DME) company, a medical doctor and two patient recruiters were each convicted late yesterday for their roles in a $4.7 million Medicare fraud scheme … to commit health care fraud and to pay and receive kickbacks. …

[Defendant] Ngari owned and operated Unique Medical Solution Inc., a Baton Rouge-area DME supplier that specialized in the provision of power wheelchairs to Medicare beneficiaries. Evidence at trial established that beginning in late 2003, Ngari paid recruiters, including Jones and Payne, to locate and solicit Medicare beneficiaries to attend "health fairs" hosted by Jones and Payne at churches and other locations. At the health fairs, doctors, including Dr. Lamid, prescribed the beneficiaries power wheelchairs that were medically unnecessary. The prescriptions were used by Ngari to submit false and fraudulent claims, on behalf of Unique, to Medicare. According to information presented at trial, the doctors, including Dr. Lamid, were paid illegal kickbacks by Payne and Jones based on the number of power wheelchair prescriptions generated at the health fairs. Jones and Payne were also paid kickbacks by Ngari on a per prescription basis.

The press release concluded: “Since their inception in March 2007, Medicare Fraud Strike Force operations in nine locations have charged more than 1,000 defendants that collectively have billed the Medicare program for more than $2.3 billion.” 

The vast majority of health care professionals do not seek to defraud the government by ordering medically unnecessary power wheelchairs, lab tests from independent providers, or PT services in exchange for kickbacks.  In deference to that reality, CMS highlighted the following note in its recent MedLearn Matters article number SE1126:  “CMS has structured the revalidation processes to reduce the burden on the providers by implementing innovative technologies and streamlining the enrollment and revalidation processes. CMS will continue to provide updates as progress is made on these efforts.”

Nevertheless, revalidation will be burdensome, especially to larger anesthesia practices that will have to revalidate many provider enrollments.  The mere fact that practices cannot plan on when to apply for revalidation, because they must wait until the receive a notice from their Medicare Administrative Contractor (MAC) any time up to March 23, 2013, is a burden.

Pending the arrival of the notices from your own MACs, be aware of the following:

1. You will have 60 days from the date of the revalidation request letter to submit complete enrollment forms. Do not try to start the process before you hear from your MAC.
2. Failure to comply may result in the deactivation of your Medicare billing privileges and a freeze on payments.
3. Be on the lookout for the letter from your MAC; it may go to your place of work, or your business office, or any other address that Medicare has on file for you.
4. You may revalidate using either the Provider Enrollment Chain Ownership System (PECOS) website or a paper CMS-855 application.  CMS explicitly prefers PECOS.
5. The application must be complete and contain your entire enrollment data.
6. Remember to send in your supporting documentation, e.g. IRS form CP-575 showing your employer identification number.
7. If you use the online PECOS system, be sure to mail in the signed certification statement within seven days.

The PECOS option is currently cumbersome, as the many anesthesiologists, CRNAs and AAs who had to re-enroll within the past several years know all too well.  Word has it that CMS plans to begin implementing some significant changes by January 1, 2012.  These changes may (and should!) include allowing document uploads and electronic signatures, enabling bulk upload capabilities for multiple revalidations from a single group, and permitting administrative staff to create their own PECOS identities so that they do not have to use the clinicians’ logins and passwords.