Download - When Enrollment Goes Wrong: Successfully Navigating and Avoiding the Pitfalls of Medicare and Medicaid Provider Enrollment

Polsinelli PC. In California, Polsinelli LLP

When Enrollment Goes WrongRoss Sallade, Raleigh, NCStephen Angelette, Dallas, TX Joe Van Leer, Chicago, IL

real challenges. real answers. sm

Introduction

Medicare 101 Understanding the Enrollment Process Developing Internal Procedures to Ensure

Compliance Consequences of Non-Compliance When Enrollment Goes Wrong

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Medicare 101

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Medicare Coverage: Parts A-D

Part A Hospital Insurance Benefits– Inpatient hospital services: room, meals, nursing services, operating

and recovery room, drugs, diagnostic tests, etc. – Extended care or skilled nursing services– Hospice and home health care

Part B Supplemental Medical Insurance Benefits– Physician services, outpatient diagnostics tests, non-self-

administered drugs (IV or injectable drugs), supplies, durable medical equipment, outpatient facility services, ESRD services

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Medicare Coverage: Parts A-D (cont.)

Part C Medicare Advantage– Under the Medicare Advantage program, beneficiaries can enroll in a

private health plan (e.g., an HMO or PPO) and receive all Medicare-covered benefits under Parts A & B, and possibly other benefits

Part D The Prescription Drug Benefit– Part D is a voluntary, subsidized outpatient prescription drug benefit

It is a benefit separate from Parts A & B For a monthly premium, beneficiaries may enroll in either stand-

alone prescription drugs plans (“PDPs”) and Medicare Advantage prescription drug plans (“MA-PDs”)

– Premiums and deductibles vary by plan

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Medicare Provider Enrollment

Enrollment is the process followed by providers and suppliers to obtain privileges allowing them to bill Medicare for services furnished to beneficiaries.

Enrollment is also a means to enable CMS to screen prospective providers and suppliers.

Enrollment screening is CMS’s first line tool to ensure the integrity of the Medicare program.

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1) Provider – Defined as institutional health care facilities, including hospitals,

skilled nursing facilities, home health agencies, hospices and others (42 U.S.C. 1395x(u))

2) Supplier– Defined as “a physician or other practitioner, or an entity (other

than a provider)” (42 U.S.C. 1395x(d)) • DMEPOS suppliers, IDTFs, physician clinics, independent

labs, radiation therapy centers, etc.

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Enrollment Requirements – Provider Agreements

All providers must enter into provider agreements with Medicare, agreeing to conform to the conditions for coverage and all applicable laws

– Provider/Supplier Enrollment Providers must submit an application to enroll in Medicare using

CMS Form 855A (includes ESRD facilities); CMS must approve the enrollment and CMS may terminate enrollment for various violations

Suppliers must submit an application to enroll in Medicare using CMS Form 855B, 855I, or 855S

– Survey & Certification Certification surveys typically conducted by the state

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Enrollment: Tools of the Trade

Provider and Supplier Enrollment Forms – the 855CMS 855A – Institutional ProvidersCMS 855B – Clinics/Group Practices, IDTFs, ASCs, and other Suppliers (non-individuals billing under Part B), not including DMEPOS suppliersCMS 855I – Individual Practitioners (physicians, NPPs) Billing Under Part BCMS 855O – Physician or NPPs for the Sole Purpose of Ordering and Referring Items and/or ServicesCMS 855R – Practitioners Reassigning Benefits under Part B CMS 855S – DMEPOS Suppliers


Enrollment: Tools of the Trade

Other FormsCMS 588 – Electronic Funds Transfer Agreement

EFT is a way for Medicare to pay provider with a money transfer from bank to bank.

This application must be included with an initial enrollment application and revalidations.

CMS 460 Participating provider agreementCMS 1561 Provider Agreement for Certified ProvidersIRS CP-575 Proof of Taxpayer Identification Number (TIN/EIN)


Practical Tips

Some entities enroll as Part A providers (855A), but provide Part B services – Dialysis facilities– Outpatient therapy providers (PT/OT/ST)– Rural Health Clinic

Hospital-based Physician Groups

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Enrollment Process

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Why Do You Submit an 855?

Initial Enrollment Changes of Information

– For example: legal or d/b/a name, specialized employees (i.e. technicians), adverse legal actions, authorized officials, and billing agency information

– Reporting Deadlines Vary Revalidation (every 5 years for most providers;

every 3 years for DMEPOS suppliers) Voluntary Termination Change of Ownership, acquisition/merger and

consolidation13


What/How Do You Submit an 855?

Paper 855 vs. PECOS PECOS is the online Medicare enrollment

database which providers and suppliers may use to submit initial, change of information, change of ownership and termination enrollment applications.

Advantages and disadvantages

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What/How Do You Submit an 855?

Location of 855 Forms: https://www.cms.gov/medicare/provider-enrollment-and-certification/medicareprovidersupenroll/enrollmentapplications.html

Location of PECOS: https://pecos.cms.hhs.gov/pecos/login.do#headingLv1

An example of the application completion process can be found here: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/downloads/pecoswebscreenexample.pdf

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Where Do You Submit an 855 and Who Touches it in the Process?

Medicare Administrative Contractors Accreditation Organizations State Agencies CMS Regional Offices CMS Central Office


Part A/B MACs Jurisdictions


CMS Regional Offices


Enrollment: The Process

Providers and Suppliers submit applications to the appropriate MAC

The MAC initially processes the application and once it is complete, issues a recommendation for approval to the State Agency

The State Agency reviews the application and may request additional information. Once it approves, the application goes to CMS Regional Office for approval

CMS then issues approval or rejection (only certain bases for rejection)

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When Do You Submit an 855?

New Enrollments:– 180 days before for Part A providers, ASCs and

portable x-ray suppliers– 60 days before for all other providers/suppliers– NEVER before re-enrollment bar or appeal following a

denial CHOI – up to 60 days prior, and 30 days post CHOW – up to 90 days prior, and 30 days post Revalidation – upon receipt

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Transaction Time: CHOW vs. CHOI

Change of Ownership (CHOW)– An asset purchase results in a CHOW

A change in the tax ID of the enrolled Provider/Supplier generally results in a CHOW

Change of Information (CHOI)– Certain transaction structures do not result in a

change of ownership, but only a CHOI– a change of control (50% or more direct/indirect

ownership/membership) or change in practice location must be reported

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Pulling the Enrollment Process Together

22Source: Decision Health, Zabeen Chong, CMS


Enrollment: The Effective Date

[insert process slide]



Enrollment: The Effective Date



Developing an Internal Process to Ensure Compliance

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Obligation to Track and Update Information on File with CMS

Required as condition of participating in Medicare to provide timely updates to any changes in information encompassed in your 855.

Need to design a tracking mechanism of what was reported, and what/when that information changes.

Need to understand timelines.

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Tracking Changes

Provider Type 30-Day Reporting 90-Day ReportingCertified Providers and Suppliers (e.g., hospice, HHA, hospital, etc.)

Change of ownership or control; changes in AOs or DOs; revocation/suspension of state/federal license

All other

Physicians, NPPs, Phys. Organizations

CHOW, adverse legal actions; change in address

All other

IDTF CHOW, change in location; adverse legal actions; changes in supervision

All other

DMEPOS All changes N/A

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What Happens When Enrollment Goes Wrong?

Return Rejection Denial Deactivation Revocation Impact on Payment

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What Can you do When EnrollmentGoes Wrong?

Return – Nothing, start over. Considered a “non-application”

Rejection – Fix the deficient sections within 30 days from the date the “Development Letter” is mailed by MAC (but be mindful of CHOW/CHOI timelines)

Denial – Corrective Action Plan, Request for Reconsideration, Appeal

Deactivation – File to reactivate, no appeal rights. Revocation – Appeal, appeal, appeal…

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Appeal Options…

Standard Process: – Corrective Action Plan (“CAP”)– Request Reconsideration– Appeal to Administrative Law Judge– DAB Review – District Court Review

Outside the Box:– Contact CMS (RO or Central Office)– Contact the MAC– Contact Congressional Representative

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Practical Tips To Avoid Enrollment Errors

Ownership of the Process – Whose job is this? Develop checklists to review prior to any filing going out

the door (e.g., right form/version; correct address; paid application fee; NPI; dated application; signed application; postage; fed ex; tracking

Form Completion Tips– Tricky sections (Sec. 4, 5, 6)– Must get SSNs, not optional– Must know date ownership/control began and report

accurately– Exact percentages of ownership needed– Watch for MAC transitions

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When Enrollment Goes Wrong

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Example #1 – Part A Provider, with Part B Billing Problem

Hospital A hires new hospitalists and intends to bill for prof. fees.

Hospital A does not have a Part B Medicare number.

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Example #2A – Effective Date

Facts: Physician Group hires MD who begins furnishing

services on March 1. Group submits a CMS-855I on May 1. Application is approved on July 1. The physician’s

effective date of enrollment is June 1.

Options?

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Example #2B – Effective Date

Facts: Provider begins providing services on March 1 and

submits application on March 1. Provider is surveyed on June 1, and receives a

number of technical deficiencies, the most substantive, failure to include background insurance information, and the information is updated within two weeks.

Provider’s effective date of enrollment issued by the MAC is June 15.

Options?

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Example #3 – Adverse Action Reporting

Facts: – Physician practice gets terminated from state

Medicaid program. – Physician fails to timely report change within 30 days

to Medicare via 855 update to Section 3 (Adverse Legal Actions). Instead, reports it 90 days late.

Action: MAC revokes billing privilegesResult: Revocation upheld.Lesson Learned?

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Example #3A – Variation on Adverse Action Reporting

Facts: – Physician’s license to practice medicine is

suspended on January 1. – Physician immediately appeals license suspension

and is reinstated on January 30– Physician fails to report suspension to CMS and it is

discovered by the MAC. Action: MAC revokes billing privilegesResult: Revocation upheld.Lesson Learned?

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Example #4 – Untimely Updates

Facts: Supplier fails to implement system to monitor and track changes of information reported in its 855B. Supplier recognizes failure to timely update information. Supplier comes to you, the compliance officer asking for advice. What do you tell him?Obligation: File updated 855B notifying MAC/CMS of changes, even if not timely, and accurately. Consider implications of revalidation timing.Risk: MAC can revoke billing privileges.Ever seen it happen? Yes, but only recently, and still on appeal. Prior history demonstrated revocation limited to failure to report more sensitive changes. Lesson Learned? Track, monitor, timely report, audit, catch the changes before they are caught by CMS or the MAC

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Example #4A – Variation on Untimely Updates

Facts:– Hospital receives revalidation request.– In preparing 855A to respond, hospital determines it has not updated

changes with regards to entities and individuals reported to CMS in 2 years.

– Hospital is concerned about the revocation possibility.Obligation:

– Prepare 855A truthfully and accurately.Risk: RevocationEver Seen it Happen? No. Not in the context of a revalidation.Why the different treatment? Potentially luck, more likely because revalidation is intended as an opportunity for a provider or supplier to update its enrollment profile.

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Example #5 – Revocation for Pattern/Practice of Billing Abuse

Facts: – Group practice enrolls with three physicians (A, B, and C) in year

one. – Year two group adds a new physician (D) in January. Physician

D begins providing services January 1, but is not approved by the MAC as a member of the group until April 1.

– Physician D’s services are billed under Physician A with Q6 modifier (locum tenens) through June 1.

– Physician A is available and providing/billing for services throughout the period Physician A’s enrollment in Medicare is revoked.

Result? – Revocation reversed.

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Example #6 – Non-Operational

Facts:– DMEPOS supplier operates at 123 Main St. for 10 years. – DMEPOS supplier relocates next door to 456 Main St.– DMEPOS supplier is concurrently revalidating its enrollment information

with CMS/NSC– NSC Site Visit Contractor shows up at 123 Main St. and nobody is

there. – NSC Site Visit Contractor calls 123 Main Street and even comes out

again. – DMEPOS supplier files its CHOI to notify NSC of its new address

location. Result?

– Supplier gets revoked for being “non-operational” and failing to report CHOI timely.

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Example #7 – Board Member Refuses

Facts:– Hospital adds 5 new board members– 2 have never worked with a health care provider and are

unfamiliar with Medicare’s enrollment requirements.– Both board members refuse to provide their DOB and SSN,

citing confidentiality concerns, invasions to rights of privacy, etc.– MAC issues development request letter for information, starting

30 day clock.

Issue: failure to timely respond will result in a rejection of the application.Solution: 2 Board members vacate their board seats or provide the information.

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Recent Developments in Enrollment

Proposed Rules from February 2016– Submission of comments

New announcements regarding revalidation efforts

Continuation of enrollment moratoria Release of new 855A form?

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