Fundamentals of Provider Enrollment Emily W.G. Towey and Jeanne L. Vance

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1 Institute on Medicare and Medicaid Payment Issues of Provider Emily W.G. Towey and Jeanne L. Vance Federal Program Integrity Initiatives 2 1

2 GAO Findings 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. Source: Medicare and Medicaid Fraud, Waste, and Abuse: Effective Implementation of Recent Laws and Agency Actions Could Help Reduce Improper Payments GAO T March 9, Medicare Provider Process by which providers become authorized to bill the Medicare program Provides a means for CMS to screen providers Medicare Resources: See 42 CFR et seq.; see also 42 CFR et seq.; CMS Program Integrity Manual Chapters 10 and 15; CMS State Operations Manual Chapter 23. 2

3 CMS Forms 855A Part A Providers Hospitals, home health agencies, skilled nursing facilities, FQHCs, ESRD 855B Part B Providers ASCs, 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 Benefits Used 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 What is so hard about filling out forms? 3

4 Types of Actions Types of Actions New enrollments Revalidations Changes of information Change of ownership, mergers and consolidations 4

5 Initial 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 (d); 42 C.F.R (b); CMS State Operations Manual Chapter D Medicare Revalidation Two Types 1. Cyclical (every three to five years) 2. Off-Cycle 5

6 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 Information, MLN Matters SE1126, Revised August 10 and December 9, 2011, available at CMS, Important Information on Revalidation, to list serve, November 4, 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) 6

7 New 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 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: 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. 7

8 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, 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. Changes of Information Provider Type 30-day Reporting 90-day Reporting DMEPOS Suppliers All Changes N/A IDTFs Change of ownership, location, general supervision, adverse legal actions All other changes Physicians, Nonphysician practitioners, physician organizations All other providers/suppliers (hospitals, HHAs, hospices, etc.) Change of ownership, adverse legal actions (e.g., licensure revocation), change in practice location Change of ownership or control (including changes in authorized or delegated officials), revocation/suspension of state or federal license 16 All other changes All other changes 8

9 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 (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 What is NOT a CHOW Transfer of corporate stock or the merger of another corporation into the provider corporation See 42 C.F.R

10 Mergers and Consolidations The collapse of two or more enrollments into one 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

11 Special 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. When to File Initial s 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 ; 42 C.F.R (e) 11

12 Interesting Portions of the 855 Forms 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? 12

13 Interesting Portions of the Forms 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 Interesting Portions of the Forms Who is a managing employee? (Section 6) Contact Persons (Section 13) Who are authorized and delegated officers? (Sections 15 and 16) 13

14 Web-based vs. Paper Applications PECOS CMS web-based enrollment system: the Provider, 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. 14

15 PECOS vs. Paper Not all enrollment filings can be accomplished via PECOS: PECOS OR PAPER PAPER ONLY 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 Initial enrollment applications for federally qualified health centers, rural health clinics, and endstage renal disease facilities Change of Ownership ( CHOW ) Mergers, acquisitions, and consolidations Part A providers enrolling to bill for Part B services Advantages of PECOS Faster Processing Faster Completion Electronic File Better Access to Information 15

16 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 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 16

17 New Rules Under Health Reform September 23, 2010 Proposed Rule (75 Fed. Reg ) May 5, 2010 Interim Final Rule (75 Fed. Reg ) February 2, 2011 Final Rule (76 Fed. Reg. 5862) Application Fees $ 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 17

18 Risk Categories 35 Limited Risk Providers Physician or non-physician practitioners and medical groups or 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 36 18

19 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 37 High Risk Providers Newly-enrolling home health agencies and newly-enrolling suppliers of DMEPOS Source: CMS 38 19

20 Screening Procedures Source: CMS 39 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 20

21 Site Visits 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 41 Background Checks and Fingerprinting 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 42 21

22 Temporary Moratoria on May be used when CMS determines a high risk of fraud, waste, or abuse Can apply to a particular provider/supplier type or geographic area Can also be imposed by state Medicaid programs Imposed in 6-month increments 43 Suspension of Payments 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 44 22

23 Pitfalls 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 45 Best Practices 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 completion 46 23

24 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? 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 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 Provider submits application to MAC; MAC recommends approval of 855 to State agency (if survey is needed, it occurs prior 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. 24

25 How to Solve Common and Interesting Problems 49 IDTF Billing Issue Problem: Denied claims for certain services, no explanation. 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

26 Board Member Blues Problem: MAC sends development letter requesting personal information about Board members. 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.) The Name Game Problem: MAC sends development letter asking for clarification relating to provider s name. 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. 26

27 The Never-Ending Application Problem: The MAC has taken over 12 months to process a new enrollment application. 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. 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. 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. 27

28 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, Medical Group A has Medicare claims that will precede the date its billing privileges commenced that are being denied. 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,