Medicare Physician Enrollment: Staying Alive

Not too long ago, a doctor could enroll in Medicare by sending a letter to CMS. Soon after, the letter became a two-page form.

But today, what was once a simple process has morphed into several forms and hours of documentation.

Whether you blame federal regulators for cracking down on high-risk providers, or those who manipulated the system for their own financial gain (spurring said lawmakers to create strict rules), practices that don’t document operational changes are putting their Medicare enrollment status in jeopardy.

The good news: By arming itself with information on the most common enrollment documentation errors, a practice can substantially decrease its likelihood of having its billing privileges revoked, or suffering other consequences.

That was the theme of a tip-infused teleconference, “Medicare Physician Enrollment: Passing Go and Staying in the Game,” recently held by lawyers Alice G. Gosfield and Daniel F. Shay, of Philadelphia-based Alice G. Gosfield and Associates.

Perhaps the biggest message listeners left with is the reality that making a simple mistake (such as failing to inform federal authorities of changes to the provider roster) can cause greater headaches down the line.

“We are in a very different environment now,” Gosfield told teleconference attendees. “The government is now taking the position that [it is] no longer interested in pay and chase.”

Shay said new regulations that took effect recently impose tighter screening requirements and background checks for new providers enrolled in Medicare. There are also more civil money penalties for falsifying information, and providers can be subjected to higher levels of review, he added.

During the teleconference, Shay gave examples of hypothetical scenarios at physician practices.

The first one: “Let’s say a Practice that operates an IDTF has been enrolled for about ten years. The practice submitted a voluntary revalidation two years ago and thinks its enrollment info is up to date. And then CMS sends a letter to the practice that says ‘a Doctor Jones had his license revoked and because the practice failed to report it within the appropriate time frame, the practice’s Medicare billing privileges have been revoked.’ The practice asks itself and asks, ‘who is Doctor Jones?’”

In this scenario, because it was not reported that the doctor hasn’t worked at the practice for eight years, the practice must take further action to regain its billing privileges, said Shay.

If no claims were submitted under the physician Jones’ NPI, the practice should be able to challenge the redaction and get it overturned, but the paperwork (filing a revised 855B, Attachment 2, to delete him as a supervising physician, and an 855R form to terminate his reassignment) is time consuming. Other potential risks include accidental billings using Jones’ NPI (leading to potential overpayment and false claims penalties), or higher levels of screening upon future provider enrollment.

“All of this could be avoided if the practice had reported the information on the front end,” said Shay.

To hear more scenarios of how practices could put themselves at risk by not filling out proper paperwork, check out the Webinar here.