What's new with Medicare enrollment?
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. The Centers for Medicare and Medicaid Services (CMS) made significant changes to the enrollment process in the spring of 2006 and again in 2011. Problems with the Medicare enrollment process, however, precede even 2006 and the AMA has long championed a streamlined process. 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.
Revalidation Initiative
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).
CMS information about the revalidation initiative
CMS information about the application fee
Keeping Your Enrollment Information Up-to-Date
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.
New Enrollment Forms
CMS also recently announced changes to the enrollment forms which are collectively referred to as the “855 forms.” The revised forms update the 2008 versions and add a new form known as the “855-O.” Among the changes CMS made, a sole proprietor who incorporates (and who is the sole owner of that business) only needs to complete the CMS 855-I form. In the past, such suppliers had to complete the CMS 855-B, CMS 855-I and CMS 855-R. However, information about the practice, such as the legal business name and adverse legal history, will still need to be reported. More information on the changes to the revised forms can be found on the CMS website.
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.
The revised and new forms are available on the CMS Provider-Supplier website.
Increased Screening Requirements
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.
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.
While CMS has issued new enrollment forms for physicians who order and refer (see above), and encouraged all physicians to enroll sooner rather than later, at this time CMS has not turned on the automated edits that would deny claims for services that were ordered or referred by a physician or other eligible professional simply for lack of an approved file in PECOS. CMS has said that it will provide advance notice to the physicians before CMS begins any such automatic denials. CMS has not announced any date as to when ordering/referring edits will be turned on.
Due to significant AMA advocacy, CMS delayed the implementation of the automated edits that would deny claims. For more background on this issue we recommend reviewing the June 30, 2010 CMS press release, MLN Matters Article published on September 17, 2010, the MLN article published on December 16, 2010 and the recent listserv announcement sent out by CMS on June 8, 2011.
More information on enrollment for ordering/referring physicians, see CMS’ fact educational article, website for ordering and referring providers and CMS’ fact sheet that addresses several enrollment issues unique to certain types of physicians.
One pager on Final Rule on Ordering and Referring Enrollment Requirements.
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.
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).
The AMA has a sample affidavit.
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.
The AMA and the Medical Group Management Association (MGMA) have developed a toolkit for members describing these changes and steps physicians can take help ensure a smooth enrollment process. (Note: We are in the process of updating the toolkit therefore please note the new requirements described at the top of this web page
Among the changes Medicare made to the enrollment process in 2006 was the requirement that physicians obtain their NPI prior to enrolling or making a change to their enrollment information. Due to the complexity of the Medicare program and their inability to effectively match a physician’s new NPI number to their old billing number internally, several physicians experienced claims processing interruptions following physician use of this new number. Leading up to and following the May 23, 2008 NPI compliance deadline, Medicare's solution to this problem was to require many physicians nationwide to re-enroll, even physicians who had been in the Medicare program for decades. This placed an extreme burden on an already severely taxed system because many Medicare contractors experienced spikes in the number of enrollment applications submitted.
Despite repeated protests by the AMA, state, and specialty medical societies, CMS made two changes to the enrollment process in the past few years that are particularly problematic for physicians that involve reporting changes to Medicare enrollment information and a new, shorter retroactive billing period.
First, physicians who have experienced a change in practice location, a change in ownership or financial or controlling interest, or and adverse legal action are required to report these changes within 30 days. All other changes must be made within 90 days. If physicians do not adhere to these timeframes, they could lose their billing privileges for at least a year if a Medicare contractor learns the changes have been made. The AMA continues to oppose and advocate against the 30-day timeframe as it is too short.
Second, prior to January 2009, Medicare permitted physicians to submit claims as far back as 27 months. However, under new rules, Medicare will only allow physicians who are enrolling in Medicare to bill back as far as 30 days prior to the date their application is considered “effective.”
For physicians this means under the new regulations, you are only permitted to bill Medicare for services furnished to Medicare patients up to 30 days before your billing effective date. The effective date is the later of:
- The date you filed an application that your Medicare contractor ultimately approves; or
- The date you began furnishing services at a new practice location.
Your “filing” date is defined as the date your Medicare contractor receives your approvable Medicare enrollment application. In the case of an application submitted using Internet-based PECOS, the filing date is the date the contractor receives all of the following:
- Your electronic enrollment application; and
- Your signed certification statement that is signed with an original signature and mailed to your Medicare contractor.
For a complete list of changes to the Medicare enrollment process please visit the enrollment toolkit for members . For more information on changes to the retroactive billing period, review the section of the toolkit titled, “2009 Changes to Medicare Provider Enrollment.” (Note: We are in the process of updating the toolkit therefore please note the new requirements described at the top of this Web page effective July 6, 2010)
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.
For more information on denials, rejections, and revocation, refer to the toolkit developed for members (Note: We are in the process of updating the toolkit therefore please note the new requirements described at the top of this Web page effective July 6, 2010).
None of this information should be construed as legal advice. Please be advised that this document has been created for educational purposes only. Note: The rules and regulations upon which this document are based are subject to change at any time. You should refer to those rules and regulations should any questions arise. If you have any questions regarding legal matters, please consult an attorney.
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.
AMA letter to CMS on off-cycle revalidation of physicians, September 23, 2011
CMS Response on PECOS Mandatory Enrollment Questions, September 7, 2011
AMA letter to CMS on August 4, 2011 on PECOS mandatory enrollment questions
AMA letter to CMS on March 30, 2011 on Enrollment Screening Requirements and Fees
Letter to CMS on November 16, 2010 on Additional Enrollment Screening Requirements
May 6, 2010 letter to CMS on New July Deadlines to Enroll for Referring and Ordering Physicians
AMA letter to CMS on November 25, 2008 on advance payments
AMA letter to CMS on November 28, 2006 on enrollment concerns
If after contacting their Medicare contractor physicians are unable to resolve their Medicare problems, physicians are encouraged to contact their state or specialty medical society for additional assistance. Also, physicians who are experiencing significant cash flow problems due to enrollment application backlogs at their Medicare contractor, are strongly encouraged to ask their Medicare contractor for an "advance payment." While not all physicians are eligible for these payments, the AMA is advocating strongly for relaxing the criteria associated with advance payment criteria until the enrollment problems have been addressed and resolved. The AMA has learned that this option is not well advertised therefore, physicians should alert their state or specialty medical societies if their contractors are unfamiliar with this option.
AMA Medicare Enrollment Toolkit
(Note: We are in the process of updating the toolkit therefore please note the new requirements described at the top of this web page)
AMA Medicare Enrollment Complaint Form
CMS Database Listing Names of Referring/Ordering Physicians Already in PECOS (32 MB)
