September 18, 2023

Though often overlooked, provider enrollment can have a major impact on the overall success of a medical group practice. Navigating the enrollment process can be tricky, especially when one considers that each carrier has its own unique set of regulations concerning who can participate and how the enrollment process must be completed.

The Priority

Due to Medicare’s strict requirements and screening processes, it is becoming increasingly common for various payers, including many states’ Medicaid programs, to require providers to enroll with Medicare prior to requesting participating group/provider status. Thus, even if Medicare is not a significant part of the group’s payer mix, Medicare enrollment may still be vital for entering other payers’ networks. For example, a pediatric group that plans to bill Medicaid of Texas must first be enrolled with Medicare before they can apply to be a Texas Medicaid participating provider.

The Centers for Medicare and Medicaid Services (CMS) is the federal agency that is responsible for ensuring that all Medicare regulations are being followed. Provider enrollment is no exception in this regard, and CMS has a team that focuses solely on provider enrollment. This team is responsible for protecting the program by ensuring that Medicare approved groups/providers meet all requirements to participate in the program. CMS has implemented many checks and balances into their enrollment process to weed out ineligible groups/providers.

The Process

Even with their checks and balances, enrolling in Medicare should not be an overly difficult process. Starting the enrollment process well ahead of providing services will help ensure a favorable effective date and reduce the risk of non-covered claims. Understanding how an organization is set up is vital for the completion of the enrollment process. The type of enrollment that needs to be completed will depend on the specific business structure. Submitting the wrong enrollment form/information will delay the process and could impact the assigned effective date.     

New sole proprietorships or sole owner groups should complete the 855I form to enroll the entity with Medicare. In contrast, partnerships, limited partnerships, LLCs, joint ventures and all types of corporations or government owned entities would complete form 855B. Individuals can be added to (a) sole owner practices, and (b) any group that enrolls using 855B form. The difference between enrolling a practice using an 855I and 855B is the reporting of ownership information. When one individual owns the whole practice, Medicare can utilize the 855I to verify that the owner meets Medicare requirements. When a medical group has more than one owner, Medicare will verify that any individual that has five percent or more ownership meets the requirements of participation.

Submitting accurate ownership information is a strict requirement. Ownership information has become a focal point for CMS’ Provider Enrollment and Oversight Group in recent years. In the fall of 2021, CMS added a Provider Ownership Verification Contractor. This third-party organization verifies that the ownership information on the application matches external sources, such as the secretary of state. If inaccuracies are found, there will be a delay in the processing. If an owner was not reported and that owner is ineligible to participate in the Medicare program, Medicare may issue an enrollment bar for up to 10 years for falsifying information to gain benefits.   

The Premises

Practice locations reported on the application should match the address as listed by USPS. Provider Enrollment, Chain and Ownership System (PECOS) is Medicare’s provider enrollment software solution that interfaces with USPS website. If there is an address mismatch, a Medicare site visit may be conducted. This site visit will focus on the facility being operational and will confirm that the group practice does, in fact, provide services within the facility. If there is a notice that a site visit will be forthcoming, any public facing employee must be aware of the group’s legal business name, which often differs from the facility name.

The Providers

All individual practitioners must first be enrolled with Medicare in the state in which the provider practices using the 855I application. If providers are working in multiple states, the provider will need to enroll in each state. Medicare is going to verify that the provider’s name on the application matches the provider National Plan and Provider Enumeration System (NPPES) profile and license.

A provider is linked to an enrolled group utilizing the 855I application. Both the provider and group authorized official will need to sign to add a provider to a group. A provider can be removed from a group by submitting an 855I along with either the provider or authorized representative signature.

All group and provider enrollment applications will ask if the providers/owners have an adverse legal action history. It is important to accurately report all adverse legal action with applicable attachments. CMS has included the regulations of what actions need to be reported on both the 855B and 855I applications. Submitting inaccurate adverse legal history can cause CMS to issue an enrollment bar.

The Period

Enrolled groups and providers will be required to revalidate their enrollment at least once every five years. Medicare can issue an off-cycle revalidation notification at any time. These notifications will be sent to at least two addresses: the special payments address and the correspondence address. If these are the same address, then a notification will also be sent to the primary facility. Failure to revalidate will result in payment holds. Continued failure will result in deactivation, and there will be a lapse in coverage from the deactivation date until the date Medicare received the re-enrollment request.

All enrolled providers and groups have agreed to maintain their enrollment records with Medicare by providing updates within 90 days of the change, including any provider who becomes employed or resigns. Adverse legal action, ownership changes, and locations additions/terminations must be reported within 30 days. Failure to report changes can result in termination from the program. Depending on the situation, Medicare may also issue an enrollment bar.

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In summation, reviewing each Medicare application prior to signing, and verifying that all information is correctly documented, will help avoid any Medicare enrollment mishaps. Keeping your enrollment record updated on any change of information will help safeguard continued enrollment. So, as one can readily see, provider enrollment—especially as it concerns Medicare—will have a direct impact on the group’s ability to succeed over the long haul.

If you have any questions on this topic, please reach out to your account executive.

With best wishes, 

Rita Astani
President—Anesthesia