Be aware of new CMS Medicare physician rules

Contract Language. By Steven M. Harris, AMNews contributor. July 14, 2003.

CONTRACT LANGUAGE

A column examining the ins and outs of contract issues

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The Centers for Medicare & Medicaid Services has proposed new requirements for physicians to establish and maintain their Medicare provider numbers. They include additional contract requirements and possible on-site inspections.

You should be aware of these proposed regulations because implementation will impact your present and future Medicare provider agreements as well as your contracts with other health care practitioners and entities.

CMS in April issued a proposed rule that would require all physicians who have not opted out of Medicare to complete an enrollment form, submit specific information to CMS, and periodically update and certify the accuracy of the enrollment information in order to initially receive and later maintain billing privileges in the Medicare program.

The comment period for these proposed regulations ended on June 24, and final regulations are expected to be published later this year.

CMS issued these proposed regulations in response to criticism that it does not adequately screen providers who defraud the Medicare program. CMS has stepped up efforts in recent years to block or eliminate unqualified or fraudulent providers or suppliers. These latest regulations continue CMS' efforts. Here's how things would work under the proposed regulations.

The CMS 855 Form, which is the Medicare Health Care Provider/Supplier Enrollment Application, requires physicians clearly identify themselves and their places of business, provide documentation that they are qualified to perform the services which they bill, certify that they are not currently excluded from the Medicare program, and certify that they meet all applicable Medicare requirements. If CMS decides that the submitted information is incomplete, invalid or insufficient to meet the Medicare requirements, then the agency has the discretion to reject, deny, deactivate or revoke Medicare billing privileges.