The Medicare enrollment process is a critical area of the program as it serves as the gateway for physicians and other health care providers into the program. Before physicians can bill Medicare they must submit an enrollment application to their Medicare contractor and have it successfully processed. Unfortunately, there have been significant problems with the Medicare enrollment process over the past several years. As a result of our recent advocacy, CMS has placed a renewed emphasis on addressing many of the systemic problems with this process. The AMA continues to communicate to CMS the Medicare enrollment concerns of physicians in an effort to mitigate these problems.
CMS usually requires a physician to resubmit and recertify the accuracy of their enrollment information every 5 years (other than a DMEPOS supplier which is every three years), a process known as “revalidation.” CMS recently announced an "off-cycle" revalidation initiative which could result in revalidations sooner than 5 years. Under CMS' original plan, the off-cycle initiative would have required many physicians to revalidate their enrollment information by March 23, 2013. However, due to significant AMA advocacy, CMS has extended the initiative to an additional two years to March 2015. Furthermore, now most physicians will not be asked to revalidate their enrollment information until the end of this initiative.
Physicians should not submit an enrollment application to their Medicare contractor solely for the purposes of revalidation until they have received a letter asking them to do so. Once a physician receives a request from their Medicare contactor to revalidate their information, they are required to respond within 60 days otherwise they risk deactivation of their billing privileges.
When physicians do receive a request from their Medicare contractor to revalidate, physicians are encouraged to submit their revalidations online, as the process is generally more expedient than when the application is completed on paper. Once a physician submits their application online they are required to immediately print, sign, date, and mail the certification statement along with all required supporting documentation to their contractor.
While most physicians are exempt from enrollment application fee, physicians who are enrolled as a durable medical equipment (DME) supplier will be subject to a fee. When revalidating, physician suppliers must pay their enrollment fee online. Fees may be submitted by electronic check, debit, or credit card. Revalidations are processed only when fees have cleared. The fees can be paid online. Once a physician completes the form and submits payment as directed, a confirmation screen will display indicating that payment was successfully made. This confirmation screen is a physician’s receipt and should be printed for their records. CMS strongly recommends physicians mail a copy of the receipt to their Medicare contractor along with the Certification Statement for the enrollment application. CMS will notify the Medicare contractor that the application fee has been paid. The AMA strongly recommends that physicians mailing any enrollment supporting documents or paper applications using a method that provides proof that the information was sent and received (i.e. return receipt).
Please note that the Medicare provider enrollment revalidation effort does not change other aspects of the enrollment process. Physicians are required to keep their information updated with Medicare and must report any changes related to their enrollment status within 30 days. Physicians should continue to submit routine changes such as address updates, reassignments, additions to practices, changes in authorized officials, information updates, etc. as they always have. A current enrollment record must be in Provider Enrollment, Chain and Ownership System (PECOS), the Medicare enrollment database, and must contain the physician's National Provider Identifier (NPI). If you also receive a request for revalidation from your Medicare contractor, respond separately to that request.
Paper forms for enrolling in Medicare can be found on the CMS website.
The Affordable Care Act (ACA) included several program integrity provisions, among them, increased screening requirements for providers and suppliers enrolling in Medicare. Due to AMA advocacy, CMS agreed that physicians pose a low risk to the integrity of the Medicare program and have elected to place most of them in the lowest risk tier category which requires the fewest screening requirements among all providers who enroll. Providers in the middle and high risk tiers will be subjected in some cases to fingerprinting and background checks. The AMA is also pleased that CMS agreed with our concerns that physicians who are victims of identity theft should not be subjected to higher scrutiny and thus placed in a higher risk tier. The AMA, however, is extremely disappointed that CMS elected to include physicians who are also DME suppliers in the highest risk category. In some cases this will mean physician suppliers could experience unscheduled site visits, criminal background checks, and fingerprinting and some will also be required to pay an enrollment fee of $505 for 2011 and $523 for 2012. The AMA continues to strongly oppose any additional screening requirements and fees for physician DME suppliers as we believe these physicians also face very little risk to the Medicare program. Read the AMA comment letter to CMS and fact sheet outlining the provisions included in the final rule to learn more.
CMS has added yet another feature to make physician online enrollment / re-enrollment easier. Physicians and other providers are now able to submit supporting documents needed to process their enrollment application, through the online PECOS system using their new Digital Document Repository. Until recently, even physicians who submitted their enrollment information online were still required to submit several paper documents separately. The DDR will apply to any documents required to be submitted as part of the Medicare Enrollment application and requests from the Medicare contractors for additional documentation that may be essential to completely process the physician’s enrollment application. Examples include medical licenses/certifications, IRS tax documents, voided checks, and the CMS-460 participation agreement form, among many others. More information, including a "how to" guide, has been made available by CMS.
In addition, Medicare now allows physicians to electronically sign and certify their application rather than having to submit a wet signature on paper. The system also now allows physicians to see if a request for revalidations has been sent by their Medicare contractor, a single screen that allows a physician to view all their enrollment information in one place, the ability to more quickly update and resubmit an application for correction via the online system, and the use of fewer screens and steps when submitting changes or revalidating information.
Medicare Streamlines Access to PECOS, EHR, and NPI database
CMS has made changes to simplify the way physicians access the Provider Enrollment Chain and Ownership System (PECOS), the Electronic Health Records (EHR) Incentive Program, and the National Plan and Provider Enumeration System (NPPES). These changes are expected to improve the user experience when registering as an individual practitioner, authorized or delegated official of an organization, or someone working within PECOS on behalf of a physician (also known as a surrogate). The new process will:
- Allow registered users to manage and reset their user ID and password online without calling a CMS Help Desk.
- Provide a simple and secure way for providers and suppliers to authorize individuals or groups of individuals to act on their behalf in PECOS and EHR.
- Allow designated authorized officials already on file with Medicare to be quickly approved to access PECOS without the need to submit documentation to CMS for verification prior to submitting the application.
- Allow organizations with potentially large numbers of credentialing or support staff to manage staff access to the various functions.
- Increase security to reduce the risk of provider identity theft and unauthorized access to systems.
Please note that if you already have a user ID and password from NPPES, or currently access PECOS, NPPES, and/or EHR, your accounts will not be affected by this change. You can continue to use your established user ID and password to access the systems. For more information see CMS’s slides and their document on Identity & Access process for online PECOS.
Medicare Now Accepts Enrollment Applications 60 Days in Advance
Until recently physicians were only permitted to send their application to their Medicare contractor 30 days in advance of the “effective date” which is the later of: 1) the date a physician filed an application that is ultimately approved by Medicare; or 2) the date a physician began furnishing services at a new practice location. Under new guidelines CMS has extended this date to 60 days, with some exceptions. The change is effective May 14, 2012. A recent MLN Matters article outlines this change.
Medicare has published a database listing all physicians and other health care professional in the PECOS system. You can determine whether or not you are in the PECOS system through the CMS website. Please note, the file is extremely large, though it is alphabetized. General information on Medicare enrollment can be found on the CMS website.
Physicians who order or certify imaging or clinical laboratory services, DMEPOS, or home health services for Medicare beneficiaries need to:
- Enroll or verify enrollment in Medicare now to avoid claim rejections. Physicians who seek to enroll for ordering or certifying only may do so via PECOS or by submitting the CMS 855-0, a paper enrollment application. Note that this requirement does not extend to physicians who have validly opted-out of Medicare.
- Retain records related to orders or certifications for 7 years. There is no requirement regarding the manner of record retention (i.e. electronic or paper).
- Use their Type I individual NPI when certifying or ordering, even if they are being reimbursed under a Type II NPI. For example, if Dr. Smith orders home health services and uses his Type II NPI for John Smith, MD LLC instead of his personal, Type I NPI, the claim may be denied (even if Dr. Smith has reassigned Medicare reimbursement to John Smith, MD LLC).
- View AMA/MGMA Fact Sheet on Medicare's Referring & Ordering Requirements.
Streamlined Application Form
The new 855-O is an abbreviated version of the other 855 forms and was created exclusively for use by providers and suppliers who refer or order services for Medicare patients but who do not bill Medicare. Many such providers and suppliers are not enrolled with Medicare today. Due to an increased focus by the government on program integrity issues, CMS is requiring those providers and suppliers who refer or order services but are not enrolled with Medicare, to enroll via the 855-O. Use of the 855-O form is effective immediately, while providers and suppliers using the 2008 CMS-855 forms (i.e. 855-I, 855-B, and 855-R - CMS-855S (02/08) listed at the bottom of the earlier versions) may continue to use the old forms through October 2011, they are encouraged to begin using the new versions (CMS-855I (07/11) listed on the bottom of each new form) as soon as possible.
Information on Medicaid
CMS has directed States to enroll ordering, referring, and prescribing physicians and other practitioners in Medicaid. This requirement does not apply to risk-based Medicaid managed care plans. CMS made clear that States have the option to establish a streamlined enrollment process for physicians whose only relationship with Medicaid is ordering, referring, or prescribing. States, however, vary in whether they are implementing a streamlined process or requiring physicians to enroll as a fully participating provider. The enrollment requirement for physicians who order, refer, or prescribe for patients who reside in neighboring states, therefore, varies by state and may depend on existing reciprocity agreements between state Medicaid programs. The AMA has developed a model state bill to create a streamlined enrollment process and will work with state medical associations interested in advocating for this legislation which can be found under on the AMA's Medicaid resource page under "Preventing Mandatory Participation Options."
If you are a physician who has opted out of Medicare, for the purpose of enrolling and referring Medicare patients to other physicians who bill Medicare, you must have an opt-out affidavit on file with your local Medicare contractor. More information on how to opt-out of Medicare has been made available by CMS. Learn about your Medicare participation options.
Physicians who opt-out of Medicare do not have to enroll in PECOS; Medicare contractors will enter information on opt-out physicians into the PECOS database instead. The following information should be supplied for an opt-out affidavit: The physician/practitioner’s legal name; Medicare specialty; TIN (SSN) (required if an NPI has not been assigned); Address; Telephone number; NPI ( if one has been assigned); and Medicare ID (if one had previously been assigned).
You can determine whether or not you are in the PECOS system through the CMS website. Please note, the file is extremely large, though it is alphabetized.
If you find that you are not on the list but should be, please complete the AMA's Medicare enrollment complaint form and we will forward this onto the CMS on your behalf. Please note, due to the number of complaints we receive, we are only able to assist AMA members.
If you are considering opting-out of Medicare but need more information, please visit the AMA's web page on Medicare participation options.
For physicians who have trouble getting their PECOS application processed online, CMS says physicians should:
- Report application navigation, printing, or access problem with Internet-based PECOS by contacting the EUS Help Desk at (866) 484-8049 or sending an e-mail to the EUS Help Desk to EUSSupport@cgi.com.
- Have Internet Explorer version 5.5 or higher and have the most recent version of Adobe Acrobat Reader before initiating an enrollment action using Internet-based PECOS.
- Ensure when calling the help desk ask that they open a "help desk ticket" to help resolve the problem.
If you have tried unsuccessfully to work with your Medicare contractor to have your application approved, physicians can complete the Medicare Enrollment Complaint form and we will forward this onto the Centers for Medicare and Medicaid Services (CMS) on your behalf. Please note, due to the number of complaints we receive, we are only able to assist AMA members.
CMS has produced a fact sheet that addresses several enrollment issues unique to certain types of physicians.
In June 2008 CMS published a final rule concerning appealing Medicare enrollment decisions. There are five possible outcomes to a Medicare provider enrollment application: 1) Physician is granted Medicare billing privileges; 2) Physician is contacted for missing information; 3) Physician’s application is returned; 4) Physician application is denied; or 5) Physician application is rejected. NOTE: Applications will no longer be “rejected” as of April 1, 2009.
Physicians have the right to formally appeal the “denial” of their Medicare provider enrollment application, as well as the “revocation” of their Medicare billing privileges. Medicare contractors are required to notify physicians of a denied Medicare provider enrollment application or a revocation of Medicare billing privileges by certified mail. In most cases, physicians will have three options when it comes to filing an appeal. They can:
- File a formal written appeal within 60 calendar days of the notice’s postmark; or
- File a corrective action plan (CAP) within 30 calendar days of the notice’s postmark; or
- File a formal written appeal with 60 calendar days and file a CAP within 30 calendar days.
If physicians do not pursue one of these options in a timely manner, they waive all their rights to further administrative review.
In the event a physician’s Medicare billing privileges are revoked, the revocation is effective 30 days from date of the postmark on the envelope containing the notice that has been mailed, except that in the case of a revocation based on a federal exclusion or debarment, revocation is effective with the date of the exclusion or debarment.
None of this information should be construed as legal advice. Please be advised that this document has been created for educational purposes only.
The AMA has been very aggressive in communicating concerns raised by physicians across the country and has called for more resources for handling enrollment applications. We continue to bring these concerns to the attention of Medicare leadership at every opportunity possible. We have discussed this matter with Medicare, hosted meetings and conference calls, offered suggestions on how to make the process work better, and brought hardship cases to the attention of Medicare for prompt resolution. The AMA has also been successful in getting Medicare to devote additional resources to this process, but we are aware much more are needed. Since the vast majority of physicians offices are small businesses, the AMA has also brought these concerns to the attention of the Small Business Administration (SBA) who champions government policies that are fairer to small business owners.