Medicare Enrollment Process
What's New with Medicare Enrollment?
Learn about the latest changes to the Medicare enrollment process as of September 2009
Background
The Medicare enrollment process is a critical area of the program as it serves as the gateway 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, a situation that has been seriously exacerbated by the transition to the National Provider Identifier (NPI) number and the transition from Medicare carriers to Medicare Administrative Contractors (MACs). CMS made significant changes to the enrollment process in the spring of 2006 and since then has continued to modify the process. Problems with the Medicare enrollment process, however, precede even 2006 and the AMA has long championed streamlining this process.
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. The end result, which continues in some cases today, are enrollment backlogs and very long delays for physicians to get their applications processed.
Medicare made further sweeping changes to the enrollment process that were effective January 1, 2009. Due to significant advocacy by the AMA, Medicare postponed many changes until April 1, 2009. The AMA together with the Medical Group Management Association (MGMA) have developed a toolkit for members (PDF) describing these changes and steps physicians can take help ensure a smooth enrollment process.
Changes to the Medicare Enrollment And Billing Process
Despite repeated protests by the AMA, state, and specialty medical societies, Medicare has indicated has made further sweeping changes to the enrollment and billing process. The AMA has advocated strongly against making any more changes to the enrollment process that could further jeopardize the already fragile process. Two of the most problematic changes that physicians need to be aware of involve new timeframes for 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.
The AMA has been successful in getting CMS to postpone the implementation of this change from January 1, 2009 until April 1, 2009 in order to ensure enrollment backlogs are reduced. For a complete list of changes to the Medicare enrollment process please visit the enrollment toolkit for members (PDF). For more information on changes to the retroactive billing period, review the section of the toolkit titled, “2009 Changes to Medicare Provider Enrollment.”
Medicare Physician Enrollment Appeals Process
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.
What has the AMA done to Make the Medicare Enrollment Process Work Better?
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 November 25, 2008 on advance payments
AMA letter to CMS on November 28, 2006 on enrollment concerns
New Online Enrollment Submission Process
In December 2008 Medicare rolled out a long anticipated Internet-based system that allows physicians to submit their enrollment applications (and make changes) online. The system is being phased into all states for use by physicians over the next few months. CMS has said it expects the Internet-based system will reduce enrollment and changes in enrollment processing by the contractor from the 60-to-90 day range to a 30-to-45 day range.
Medicare Advance Payments
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.
