Fundamentals of Provider Enrollment

Transcription

1 Fundamentals of Provider Enrollment INSTITUTE ON MEDICARE AND MEDICAID PAYMENT ISSUES Disclaimer: The content of this presentation does not constitute legal advice. 1 Types of Enrollment Actions When and Where to File Applications Web-based vs. Paper Enrollment Applications Interesting Portions of the 855 Forms Enrollment Rules Under Health Reform Heightened Medicaid Enrollment Screening Processes Enrollment Pitfalls and Best Practices 1

2 Medicare Provider Enrollment Process by which providers become authorized to bill the Medicare program Provides a means for CMS to screen providers Medicare Enrollment Resources: See 42 C.F.R et seq. See also 42 C.F.R et seq. CMS Program Integrity Manual Chapter 15 CMS State Operations Manual Chapter 3 2 CMS Enrollment Forms 855A Part A Providers 855B Part B Providers 855I Physicians and Non-Physician Practitioners 855R Reassignment of Medicare Benefits 855S DME Suppliers 855O Ordering & Referring Physicians & Non-Physician Practitioners 588 Electronic Funds Transfer Authorization Agreement 460 Participating Provider Agreement 3 2

3 What is so hard about filling out forms? 4 Types of Enrollment Actions Initial enrollment Revalidation Change of information 5 Change of ownership, mergers and consolidations 3

4 Initial Enrollment 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 6 Medicare Revalidation Two Types 1. Cyclical (every three to five years) 2. Off-Cycle 7 4

5 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 8 Patient Protection and Affordable Care Act, Section 6401(a); CMS, Further Details on the Revalidation of Provider Enrollment Information, MLN Matters SE1126, Revised August 10 and December 9, 2011, available at CMS, Important Information on Revalidation of Provider Enrollment, to ALL-FFS-PROVIDERS@LIST.NIH.GOV list serve, November 4, Consequences of Ignoring a Revalidation Request Deactivation provider/supplier can apply to reactivate 9 Revocation provider/supplier may not reapply until the period of the enrollment ban passes (one to three years) 5

6 Now Required Enrollment Forms The exact date that ownership or control began for direct or indirect owners, officers, directors, managing employees and lienholders The exact percentage of ownership (not control) The date and place of birth of officers, directors, managing employees, and direct and indirect owners Identities of all physician owners of physician-owned hospitals 10 Revalidation Practice Tips Keep the envelope for the revalidation request. Consider affirmatively revalidating if you are reporting changes anyway. 11 Check the CMS revalidation list at: 11_Revalidations.asp#TopOfPage 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. 6

7 Revalidation Practice Tips Keep copies of the revalidation applications; keep proof of delivery with the date of delivery. Pre-enroll to submit the revalidation application electronically in the Provider Enrollment, Chain and Ownership System ( PECOS ), if desired. Review revalidation requests by provider transaction access number ( PTAN ); many entities will have more than one PTAN and will need to revalidate each one. Assemble your revalidation application(s) in advance. 12 Changes of Information or "CHOI" 13 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 All other changes All other changes 7

8 Real Life Problem Changes of Information 14 Physician did not timely report his termination from eligibility to participate in the Illinois Medicaid program. He reported the matter three months after the occurrence, rather than within the 30 days required. DAB upheld the revocation. Parrish v. CMS, Civil Remedies Division Departmental Appeals Board DHHS Decision No. CR2449, October 12, 2011 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 15 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 8

9 What is NOT a CHOW 16 Transfer of corporate stock or the merger of another corporation into the provider corporation See 42 C.F.R Special Rule Home Health Agencies 17 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

10 Special Enrollment Issues for IDTFs Equipment Supervising and/or interpreting physicians Technicians and credentials 18 Changes to ownership, location, general supervision and adverse legal actions within 30 days; all other changes within 90 days. When and Where to File Applications 19 10

11 When to File Initial Enrollment - Up to 60 days prior to the date that the provider is to commence providing services for most providers/ suppliers Initial Enrollment - Providers submitting 855A, ASCs and portable x-ray suppliers up to 180 days prior to the date 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) 20 Where to File File with the Medicare Administrative Contractor (MAC) assigned to the provider/supplier s geographic region/ provider/supplier type A/B MACs by geographic region DME MACs 21 Home Health/Hospice MAC 11

12 Figuring Out the Right MAC; Beware of Transitions 22 MACs are being consolidated through a competitive bidding process (CMS to reduce A/B MACs from 15 to 10) Cycle of a transition consists of a contract award, an announcement, a bid protest, an appeal and the announcement of an implementation schedule See Contracting/MedicareContractingReform/index.html An Example of a MAC Consolidation/Transition Jurisdiction E (formerly J1) A/B MAC Contractor for California, Hawaii, Nevada, American Samoa, Guam and Northern Mariana Islands awarded to Noridian on September 20, 2012 Announcement made by CMS; transition to occur early Two bid protests filed October 2012 January 18, 2013, GAO denies bid protests February 1, 2013 court appeal filed Old MAC (Palmetto GBA) continues to administer claims for now 12

13 Moral of the Story 24 It is not always crystal clear where to send the enrollment application. Contact information/websites for CMS and the MACs are not always timely updated. A passing awareness of the MAC consolidation issue as it applies to your jurisdiction will help identify whether you are likely to have an issue or not. An application sent to the wrong MAC will be rejected. Web-based vs. Paper Enrollment Applications 25 13

14 PECOS 26 CMS web-based enrollment system: the Provider Enrollment, Chain and Organization System. The system is still under development; recent enhancements have made it more user-friendly, but it still has limitations. PECOS vs. Paper Not all enrollment filings can be accomplished via PECOS: 27 Most initial enrollment applications Change of Information Add or change a reassignment of benefits Revalidation of enrollment information Reactivation of an existing enrollment record Voluntary termination Change of Ownership Initial enrollment applications for federally qualified health centers, rural health clinics, and end-stage renal disease facilities Mergers, acquisitions, and consolidations Part A providers enrolling to bill for Part B services 27 14

15 Advantages of PECOS Faster Processing Faster Completion Electronic File 28 Better Access to Enrollment Information Enhancements to PECOS 29 Recently-implemented enhancements: New Provider Home Page My Enrollments Page Fast Track Revalidation Primary and Secondary Reassignment Locations Practice Locations by County Electronic upload of supporting documents Fewer duplicative document submission requirements Reassignment reports Medicare ID reports Coming soon, according to CMS: Batch upload capability Streamlined processes for group practices ADI Accrediting Information 15

16 Access to PECOS 30 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 Interesting Portions of the 855 Forms 31 16

17 Interesting Portions of the Forms What is your legal business name as reported to the Internal Revenue Service? (Section 2B1) Name on file with the IRS 32 Abbreviation, capitalization, etc. may be different than that on file with your Secretary of State. Interesting Portions of the Forms What are reportable adverse actions? (Section 3) Real Life Question Two physicians who shared ultimate responsibility for ordering the administration of a general anesthesia drug for a patient experienced a 20-day licensure suspension. The physicians did not report the licensure suspension to CMS. The MAC (Highmark) revoked their enrollments and issued a bar on re-enrollment for one year. Physicians argued that when the 30-day reporting date occurred, their licenses were no longer suspended so they had no obligation to report the suspensions. DAB determined that the revocation was proper and upheld the enrollment ban. Brown and Obeng v. CMS, Civil Remedies Division Departmental Appeals Board DHHS Decision No. CR2145, June 9,

18 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. 1320a-7 34 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) 35 18

19 Enrollment Rules Under Health Reform 36 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 CY2013 Only apply to institutional providers Must be paid for: Initial enrollment Addition of practice location Revalidation Limited hardship exception request Paid through PECOS 37 19

20 RISK Categories 38 Limited Risk Providers 39 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 20

21 Moderate Risk Providers 40 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 High Risk Providers 41 Newly-enrolling home health agencies and newly-enrolling suppliers of DMEPOS Source: CMS 21

22 Screening Procedures 42 Source: CMS Moving to a High Risk Category 43 Exclusions Payment suspensions Medicaid terminations For 6 months after CMS lifts a temporary moratorium Certain final adverse actions Certain actions involving owners 22

23 Enrollment Site Visits 44 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 Background Checks and Fingerprinting 45 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 23

24 Heightened Medicaid Enrollment Screening Processes 46 Heightened Medicaid Enrollment Screening Processes Federal regulations governing Medicaid enrollment: C.F.R et seq. April 1, 2012: States required to submit a State plan amendment to CMS to provide assurance that they will comply with new Medicaid enrollment screening rules 24

25 Heightened Medicaid Enrollment Screening Processes Enrollment Application Fees State Medicaid Agencies must collect enrollment application fee prior to executing a provider agreement from a prospective or re-enrolling provider. This requirement does not apply to: Individual physicians and non-physician practitioners Providers that have paid the application fee to a Medicare contractor or another State s Medicaid program. Provider Screening Levels 48 States are required to implement categorical risk levels similar to those implemented in the Medicare program i.e. Limited, Moderate, and High Heightened Medicaid Enrollment Screening Processes 49 Disclosure of Ownership and Control Individuals and entities with 5% or greater direct or indirect ownership or control of an enrolling provider must provide the State Medicaid Agency with the following information: Full name Social Security Number/Tax ID Number Date of Birth Other Disclosing Entities under common ownership must also be disclosed on the enrolling entity s Medicaid application regardless of whether the entity also participates in a federal health program. Individuals with 5% or more ownership or control of a moderate or high risk provider may be subject to criminal background checks and fingerprinting. 25

26 Heightened Medicaid Enrollment Screening Processes Ordering/Referring Rule for Medicaid Providers Revalidation or re-enrollment of Medicaid enrollment applications every 5 years Site visits 50 Enrollment Pitfalls and Best Practices 51 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 26

27 Enrollment 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 52 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? 53 27

28 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 Enrollment 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 Enrollment 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. 54 How to Solve Common and Interesting Enrollment Problems 55 28

29 Ravalidation Request Issue: Provider has failed to report organizational changes to CMS. 56 Problem: Provider received a revalidation request from CMS. Provider is concerned that its enrollment file is not up-to-date and that is will be sanctioned for failure to report changes on a timely basis. Solution: Go ahead and truthfully report changed information on the revalidation application. CMS has indicated that the purpose of this revalidation effort is to ensure all records are up-to-date and does not generally contemplate sanctioning providers for failure to report changes timely unless the failure would have rendered provider to be ineligible for enrollment. Authority: (click on Provider Enrollment ) 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

30 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.) 58 Special Rules for Specialties Problem: MAC sends development letter requesting that a practice location must be enrolled under the main physician group PTAN 59 Issue: Oncology Physician Group A would like to consolidate with Oncology Physician Group B under Group B s Tax ID number. Group A wants to separately enroll its practice location and bill using its own PTAN. Solution: Educate the physician specialty practice group it cannot be assigned multiple PTANs under the same Tax ID number. 30

31 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. 60 PECOS H*LL 61 Problem: Physician submits electronic application in PECOS. There are issues with the online system and the physician is unable to edit the application. The physician tries to resolve the issues several times with PECOS support help desk. Physician is unable to certify the accuracy of the PECOS-filed application and the application is rejected. Issue: What can the physician do to salvage a PECOS application gone bad? Solution: OK to try PECOS, but as soon as it get ugly, abandon and submit on paper. 31

32 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. 62 CHOW or CHOI Problem: Hospital A is affiliating with 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. 63 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. 32

33 Retroactive Billing 64 Problem: Medical Group A filed paper 855B application on November 5, 2012 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. However, it is likely that the medical group will be able to bill for services delivered up to 30 days prior to the approved enrollment date Douglas v. CMS, Civil Remedies Division Departmental Appeals Board Decision No. CR2406 DHHS, August 3, QUESTIONS 65 Disclaimer: The content of this presentation does not constitute legal advice. 33