Daniel F. Shay, JD

In September 2010, U.S. Department of Health and Human Services Inspector General Daniel Levinson explained in congressional testimony that the Medicare enrollment process needed to be used as a means of "locking the front door" to the Medicare trust fund. New regulations have been published subjecting applicants to scrutiny ranging from database searches to verify information contained in the enrollment applications, to site visits, to checking fingerprints against criminal records. These new screening processes will be applied to all new enrollees now and to current providers soon.

These efforts represent an ongoing, increasingly intrusive attempt to prevent bad doctors from gaining access to the Medicare trust fund in the first place, rather than chasing down monies paid to them in an effort to recoup losses.

Meanwhile, providers who already have Medicare billing privileges must periodically update their information through the revalidation process and must report changes to their information on an ongoing basis. This article explores some of the complexities of the enrollment process, focusing specifically on four potential problem-areas for physician practices. Difficulties may arise when noting changes in location and staff, reporting owners and managers, practicing in multiple jurisdictions, and timing enrollment submissions.

OUT-OF-DATE INFORMATION

Physician practices must notify the Centers for Medicare and Medicaid Services (CMS) of changes to their office location within 30 days. Failure to do so may result in revocation of billing privileges.

For physician practices that maintain multiple satellite offices, this issue can be of critical importance.

Moreover, for certain types of providers (including independent diagnostic testing facilities, portable x-ray suppliers, and physical therapy practices), CMS may now conduct unannounced site visits both before granting billing privileges and after. If the location is not operating when CMS visits, it may revoke the practice's billing privileges.

In fact, in a recent report from the Miami area Office of Inspector General (OIG), the OIG determined that of the 27 (out of a total of 92) independent diagnostic testing facilities that failed their site visits, 23 were not at the locations on file with CMS.

In practical terms, the most likely scenario that would trigger this predicament is where the practice maintains satellite offices and fails to notify CMS upon closing an office. It is essential to remember that CMS must be notified both when a new location is opened and when an old location is closed.

Similarly, when a physician ceases working for a practice, either the physician or the practice must submit another CMS-855R form to terminate the reassignment. If this is not done, it can lay the groundwork for future problems. Without terminating the reassignment, CMS will continue to believe the physician works for the practice. If the physician runs afoul of an "adverse legal event" (like loss or suspension of a license), the information must be reported to CMS within 30 days.

Of course, if the physician no longer works for the practice, the practice may be completely unaware of this development. But if it never terminated the reassignment and removed the physician from its enrollment record, and CMS still believes the physician works for the practice and the practice has a duty to report the event, then CMS may revoke the practice's billing privileges. It therefore is critical for practices to remove physicians from their enrollment records (including terminating reassignments) promptly, just as they must do with old office locations.