Medicare & Medicaid Provider Enrollment

1 Medicare & Medicaid Provider EnrollmentPresented byZabeen Chong, DirectorProvider Enrollment & Oversight GroupCenter for Medicare & Medicaid ServicesCharles Schalm, Deputy DirectorProvider Enrollment & Oversight GroupCenter for Medicare & Medicaid Services2 Session Overview How Enrollment Works Medicare Policy Updates Medicaid Enrollment Revalidation Our Enrollment Systems Protecting the Program Enforcement ActionsFirst thoughts3 Listening to youFinding a balanceAlways improvingWe hear you, and we ve learned a lot from believe Enrollment should be easyfor most providers, and hardfor bad will keep refining our systems, policies, transparency, and our Enrollment works4 How Enrollment works5* If the app is complete, and no site visitOnline45 days*Direct Input855 Form 60 days*Submission1 MAC mail room Manual data entryIntake2 PECOSP rocessing, Screening& Verification3 Pre Screening signed + dated app fee (or waiver) supporting docs all data elementsRisk Based Fingerprints Site VisitsVerification Name / LBN SSN / DOB NPPES Address License Adverse Actions4 Development Letter 5 Update claim system MAC updates claim system (1-2 days) Provider not approveduntil claims updatedMAC Recommendation to State /RO Certified providers/suppliers MAC recommends to RO RO performs in 3-9 moFinalization& Claims Update6 Submit to MACM edicare Providers &Suppliers(w/NPI)What causes delays?

2 630-35%delayedneed at least 1 round of corrections missing documentsIRS documents, CMS 588 EFT, voided check, bank letter, education documentation, par agreement, cert term page, org charts missing fields missing signature/date wrong signature (paper) incorrect information missing application feeNo response? delays rejections later effective email fax phone letterContacts person (sec 13) Provider (sec 2) Del Official (sec 15/16)30days to respondHow the MAC develops for missing informationMAC Notification Letters7 Who is listed on MAC notification letters? MAC analyst isthe point of contact listed on the letterMAC call center is the point of contact listed on the letterMedicare effective dates | Part B8 Option A: Early SubmissionPhysicians / Groupscan apply 60 days prior ** Provider seeking effective dateJUNE 1 Effective date is the later of: Application Receipt Date Date of first services at a new location (up to 30 days prior to application receipt)Option B: Late SubmissionPhysicians / Groupseffective date up to 30 days prior to submission date **MARAPRM AYJUNJULAUGSEPOCTMAC receives appJ U LY 1 MAC approvesMAY 15 (w/ effective June 1) Provider performsserviceJUNE 1 MAC PROCESSINGP rovider performsserviceJUNE 1 MAC receives appAPR 1 MAC approvesSEPT 1 (w/ effective June 1)MAC PROCESSING** Must be in compliance at requested effective date (operational, licensed) Medicare effective dates | Part A9** Must be in compliance at requested effective date (operational, licensed)Hospitals /HHAs /SNFscan apply up to 180 days prior **Effective date is based on.

3 Completion of survey Regional Office determines all requirements are metProvider seeking effective dateOCT 1 2016 MACreceivesappMARCH 16 MAC recommends approval to ROJULY 1 16RO approves, w/ effective Oct 1 2016 MAR 16 JUN 16 OCT 16 JAN 17 MAR 17 JUN 17 PROCESSINGRO PROCESSINGE nrollment Arrangements (Telehealth)10MM8545| Inter-jurisdictionalReassignmentNovitas( MAC)First Coast (MAC)Maryland(855I)123 Main SmithJones Medical GroupMaryland(855B)123 Main Medical GroupFlorida (855B)456 Elm Fees11 supports Provider Enrollment and screening activities required for institutional providers when initially enrolling, revalidating or adding a practice locationHome Health Agencies, DME supplier, Hospital, IDTF application fee varies from year-to -year must be paid electronically via PECOS credit or debit card (no checks permitted) MACs will develop for missing application fees and reject the application if not submitted within 30 daysA refund may be issued hardship exception request is approved application was rejected prior to the MAC s initiation of the screening application denied due to temporary moratorium not required for the transaction in question or not part of an application submission Refund request For information on which actions trigger the application fee requirement by Provider /supplier type refer to the Application Fee Matrix on the application fee at application fee for 2017 is $560 Policy Updates12 Authorized and Delegated Officials CMS 855 & I&A13 Assign surrogacy and controls access to PECOS and NPPES records Less restrictive AO requirements than 855 Automatically approved if listed as AO on 855.

4 If not, CP575 must be provided to approve access Manage staff and connections for the employer Approve DOs for the employerEnroll, make changes and ensure compliance with Enrollment requirements CEO, CFO, partner, chairman, owner, or equivalent appointed by the org May sign all applications (must sign initial application) Approves DOsAppointed by the AO with authority to report changes to Enrollment information Ownership, control, or W-2 managing employee Multiple DOs permitted May sign changes, updates & revalidations (cannot sign initial application)Authority to assign surrogacy and controls access to PECOS and NPPES records Delegated by the AO of org Provider or 3rd party org May add the employer to his profile, manage staff and connections for the employer Multiple DOs permittedWho can sign the Enrollment application?14 Initial: Changes & Revals: All: Adding: Changing/Terminating: Certification statement requirements15 Contact Person16 any contact listed on an Enrollment record may request a copy of approval and revalidation letters MAC will send email fax mail (excludes certification letters or Tie In notices issued by Regional Office) email fax letterRequests may be submitted Contact person (sec 13) Provider (sec 2) Del Official (sec 15/16)How to end date a contact person?

5 Addition of contact persons must still be reported on appropriate CMS-855 When to Select Change/Add/Delete17 Applicable CMS-855 sections (change/add/delete options) information (855A/855B/855I/855S) Control (855A/855B/855I/855S) Agency (855A/855B/855I/855S) (855A/855B/855S) 1&2 (855B)For information on which actions trigger the application fee requirement by Provider /supplier type refer to the Application Fee Matrix on to SE1617 for reporting requirements Replace existing information with new information (ex. practice location, ownership ) Update existing information(ex. change in suite #, telephone #) App fee is notrequired Add additional Enrollment information to existing information (practice locations) App fee is required Remove existing Enrollment information App fee is notrequired Deleting a practice location in PECOS removes the special payment address and requires re-entryOrdering and Certifying18 Anyone who orders or refers services:enroll in MedicareCMS-6010since Jan 2014 Reduces fraudClaims affected:See article SE1305for all edits Clinical laboratories: ordered tests Imaging centers: ordered images DMEPOS: ordered equipment, supplies Home Health Agenciesoropt-out through an affidavitState-licensed residents may enroll to order or refer using the CMS-855O, and may be listed on claims.

6 Claims for covered items and services from un-licensed interns and residents may still specify the name and NPI of the teaching physician. Ordering and Certifying19 Convert from an ordering and referring only Provider to a billing Provider and vice versa No break in billing The effective date of the withdrawn 855O is one day prior to the effective date of the 855 IConverting CMS-855O to CMS-855I Enrollment via PECOS Follow current process for creating a new application PECOS displays existing approved Enrollment and uses it to pre-populate the new application Provider must confirm the withdrawal of the existing 855O enrollmentCMS-855 OCMS-855 IConversion Steps:Updates to Program Integrity Manual20 MACs should not call to speak directly to providers reporting a change in specialty MACs should not request a diploma or degree unless education requirements cannot be verified online MACs should not request a SSN card or driver s license for identification. MACs should not request a phone, utility, power bill or lease to validate LBN or DBA Lease only required to validate exclusive use of facility for PT/OT or ambulance suppliers leasing aircraft For applications that require development, MACs shall only request the dated signature of at least one authorized/delegated officials Approval letters will list all changed/updated information for change of information to Program Integrity Manual21 CMS-855R processing guide addendum to PIM chapter 15 on used by MACs and providers includes application completion and processing instructions CMS-855O processing guide (Coming Soon) addendum to PIM chapter 15 on used by MACs and providers includes application completion and processing instructionsCMS-855R Processing Guide22 For Providers |For MACsCMS-855R Processing Guide23 For Providers |For MACs Communications regarding the processing of the CMS-855R shall be sent to the contact person listed.

7 If multiple contact persons are listed, the MAC shall contact the first contact person listed on the application. If they are not available, the MAC shall contact the other person(s) listed, unless the individual practitioner indicates otherwise via any means. Verification must occur of licenses and or certifications. The only licenses that must be submitted with the application are those required by Medicare or the state to function as the supplier type in question. Licenses and permits that are not of a medical nature are not required, ..If the MAC is aware that a particular state does not require license/certification and the Not Applicable boxes are not checked in Section 2C, no further development is needed. CMS-855O Processing Guide24 For Providers |For MACs If the physician/eligible professional is submitting an initial Enrollment application a PTAN need not be listed, as one has not been assigned; the physician/eligible professional can enter the word pending in this field or leave the field the 855O Enrollment is being terminated, the PTAN should be The MAC may use the shared systems, PECOS, or its Provider files as a resource for determining the PTAN before developing for this information.

8 A physician/eligible professional need not submit a copy of his/her degree unless specifically requested to do so by the MAC. To the maximum extent possible, the MAC shall use means other than the physician s submission of documentation-such as a State or school Web site - to validate the person s educational status. Program Integrity Manual Revamp25 more user friendly new structure driven by application and Provider type remove outdated and inaccurate information consolidate sections identifying similar processes add new and clarify existing policy Target Completion: Early 2018 For Providers |For MACsProgram Integrity Manual Revamp26 If the revalidation application is received but requires development ( , missing information such as application fee, hardship request, PTANs, documentation, signature), the contractor shall notify the Provider or supplier via mail, phone, fax or The contractor shall not require further development for missing documentation if the information already exist on file with the contractor (.)

9 For Providers |For MACsProvider Enrollment Moratoria272014 Initial implementationJuly 2013 HHA and HHA sub-units (Miami, Chicago) Ambulance and ambulance suppliers (Houston)LiftedJul 2016 Emergency ambulance services Expanded and extended Jul 2016 State wide HHA and HHA sub-units (Florida, Illinois, Michigan, Texas) Non-emergency ambulances and ambulance suppliers (New Jersey, Pennsylvania, Texas)Expanded and extendedJan 2014 HHA and HHA sub-units (Miami, Ft. Lauderdale, Detroit, Dallas, Chicago) Ambulance and ambulance suppliers(Houston, Philadelphia, surrounding New Jersey)20132016 For more information refer to the Federal Register notice at Jan and July 2017 State wide HHA and HHA sub-units (Florida, Illinois, Michigan, Texas) Non-emergency ambulances and ambulance suppliers (New Jersey, Pennsylvania, Texas) Medicaid Enrollment 28 Medicaid Provider Enrollment29 CMS Center for Program Integrity manages Medicareand Medicaidenrollment. AdvantagesLess burden for states and providersIn some cases, states can screen Medicaid providers using our Medicare Enrollment data (site visits, revalidation, application fees, fingerprinting).

10 More consistency among statesClearer sub-regulatory guidanceEach state has a CMS point-of-contactMedicaid Provider Enrollment Compendium (MPEC)Similar to the Medicare Program Integrity ManualMedicaid Provider Enrollment Compendium30 MPEC Updated Jun 2017 for State Medicaid Agencies (SMA) and providers guidance on federal Medicaid Enrollment standards (42 CFR 455 Subparts B, E) states may be stricter than Federal regs find at guidanceRevalidation (Section , ) required every 5 years (includes ordering and referring physicians) discretion to require revalidation on a more frequent basis conduct full screening appropriate to Provider s risk level may rely on Medicare or another state s screening Approval letters (Section ) SMAs should not request MAC welcome letter as a condition of Provider enrollmentOwnership Discrepancies (Section ) SMAs recommended to report ownership discrepancies for dually enrolled providersRetroactive Dates of Service (Section ) SMA makes determination to grant a retroactive billing date based on complianceRelying on Medicare Screening31 SMA determines to what extent it may reduce its own screening through reliance on Medicare s screening activities States MAY rely upon Medicare screening, however are not required to For SMAs to rely on Medicare 's screening: must have occurred in the last 5 years must be the same Provider in Medicare must be an approved Medicare providerRisk CategoryComparisonRisk CategorySMA ActionMedicaid Risk CategoryMedicare RiskCategoryNoneMedicaid Risk CategoryMedicare RiskCategoryGap ScreeningMedicaid Risk CategoryMedicare RiskCategoryNone* Exception for DME and HHA risk levelsPECOS State Page | Provider Info32 PECOS State Page | Medicare Details31 Medicare Provider Info:Practice Location Info.