Provider Enrollment
Breaking new ground in healthcare begins and ends with provider enrollment.
In the midst of healthcare reform, strict regulatory compliance has become increasingly vital in maintaining revenue streams, as well as providing optimal healthcare to patients.
Providers must consistently exercise due diligence in order to stay up to date on a vast array of present and proposed regulations that may impact the industry. In doing so, providers will develop strong business development habits enabling them to take advantage of financial incentives and avoid payment delays, while also maintaining high quality of care standards.
Provider Enrollment is an ever-changing sector of healthcare that fluctuates largely with new regulations.
Advis is continuously monitoring changes with Medicare/Medicaid enrollment rules to ensure we stay ahead of the curve. Exact Match and enrollment changes are a few examples of initiatives we have mastered after almost 40 years of working with these processes.
Learn More About Provider Enrollment
What types of providers must engage in provider enrollment?
In order to maximize financial benefits, all healthcare providers must engage in provider enrollment. This includes organizations, such as institutional providers and practitioner groups. However, provider enrollment also extends to individual practitioners, such as physicians and nurse practitioners. A common scenario occurs when an individual practitioner is providing services at a location, such as a hospital or a clinic. In this instance, both the individual and the organization must be enrolled in Medicare.
Depending on the type of agreement between the individual and the healthcare organization, both of them may be required to complete various provider enrollment applications in order for the healthcare organization to bill on behalf of the individual for Medicare services rendered. Generally, the same applies at the state level with regard to Medicaid however, it must be kept in mind that each state applies their own unique rules and regulations with regard to provider enrollment.
How do I begin the provider enrollment process?
PECOS (Provider Enrollment, Chain and Ownership System) is the most efficient method of submitting your application, as it guides each provider through the enrollment application ensuring that only relevant information is provided. In addition, PECOS reduces the amount of incomplete applications resulting in costly rejections and time-consuming requests for additional information.
In any event, PECOS submissions allow providers to choose from a wide variety of applications. The various types of applications include the following:
CMS-855A – Institutional Providers CMS-855B – Clinics and Group Practices CMS-855I – Physician and Non-Physician Practitioners / Reassignment of Medicare Benefits CMS-855S – Durable Medical Equipment Prosthetic Orthotic and Supplies (DMEPOS) Suppliers CMS-855O – Eligible Ordering and Referring Physicians and Non-Physician Practitioners
Why would a provider need to submit a CMS-855 application?
Completing an initial provider enrollment application can often be described as the “ground floor” in terms of healthcare providers. As long as Medicare or Medicaid services are being rendered, providers will continuously be subject to provider enrollment rules and regulations. As a result, providers must consistently notify CMS of any and all changes, no matter how insignificant they may seem. For example, providers must promptly complete regulatory filings for changes involving a practice location address, billing agency, or board of directors members. More noteworthy changes include those related to licensure and accreditation or certification status. The most complex issues with regard to regulatory filings arise when a provider elects to undergo a change of ownership (CHOW), acquisition/merger or consolidation.
Revalidation Applications
In compliance with Section 6401 (a) of the Affordable Care Act, all providers and suppliers that were enrolled prior to March 25, 2011, have revalidated their enrollment information under new enrollment screening criteria at least once with their applicable Medicare Administrative Contractors. The Revalidation efforts remain intact, with all providers requested to revalidate their information every five years after initial enrollment or last revalidation approval date, except DMEPOS providers, who need to revalidate every three years.
Provider-Based and 340B Impact
In addition, provider enrollment is a key component in obtaining provider-based status and 340B eligibility. Provider-based status enables healthcare facilities not located within the four walls of a main hospital to realize financial and administrative benefits in that they are treated as being a department of the hospital. In order to do so, the provider-based entity must first be enrolled as a practice location of the main hospital in order to properly bill under the hospital’s Medicare provider number.
Provider-based departments dispensing/administering 340B drugs must be enrolled within PECOS as Medicare Practice locations in order to receive Medicare reimbursement. Moreover, HRSA uses a hospital’s Medicare enrollment when validating 340B eligibility for hospitals, during registration of parent and child sites, as well as during the annual 340B recertification period. Therefore, Medicare enrollments and 340B program registration go hand-in-hand. Most covered entities elect to enroll Medicare Practice locations as 340B child sites and use the Medicare enrollment record to determine 340B eligibility of new practice locations.
Who processes Medicare provider enrollment applications?
Ultimately, the Centers for Medicare & Medicaid Services (CMS) are the governing body with regards to Medicare provider enrollment. However, Medicare Administrative Contractors (MACs), play a crucial role in the provider enrollment process. Pursuant to Section 911 of the Medicare Prescription Drug Improvement, and Modernization Act (MMA) of 2003, CMS established MACs as multi-state, regional contractors responsible for administering both Medicare Part A (institutional) and Medicare Part B (professional) claims.
MACs were created in order to improve Medicare’s administrative services to beneficiaries and health care providers through the use of new contracting tools, including competition and performance incentives. After being integrated in the provider enrollment process in 2006, MACs have been successfully enrolling healthcare providers in the Medicare program, as well as serving as a driving force in creating various cost-effective Medicare claims processing business operations.
Medicaid Provider Enrollment
Medicaid provider enrollment is submitted to and processed by the individual state agency. While some states follow Medicare guidelines, many have formulated their own criteria. For example, provider type recognition and enrollment eligibility can differ for each state. Therefore, each state has their own enrollment processes and approval timeframes.
State Medicaid agencies have access to Medicare enrollments; thus, depending on the state, Medicare may need to be should be completed prior to Medicaid submissions. Ideally, the Medicare and Medicaid enrollments should contain consistent information.
Timeliness is crucial
Providers must always be conscious of changes and updates that may trigger reporting obligations. This will require time-consuming business practices as providers must maintain important information on file with reporting agencies, including addresses (practice locations, billing, correspondence, etc.), NPI numbers, and ownership information (corporate and individual). For example, providers must report site additions, CHOWs, or governance changes within dedicated timeframes. Often times this will require the provider to report changes to multiple governing bodies, such as the state and the Joint Commission. Therefore, it is important that providers maintain an organized database of information enabling them to track all previous and upcoming regulatory filings.
Advis’ Provider Enrollment Expertise
The consultants at Advis have established a well-directed, yet diverse, understanding of provider enrollment. Through our in-depth strategic planning and effective communication methods, we have continuously apprised our clients of the most recent regulatory developments that may impact the manner in which they provide healthcare services. A sampling of the services that Advis can provide are as follows:
- Allow providers to outsource the provider enrollment responsibilities
- Educate providers on the most recent regulatory developments in order to strengthen their internal provider enrollment practices
- Furnish provider enrollment “clean up” services for all venues of care
- Application review to ensure accuracy prior to submission
- Serve in an advisory role for provider enrollment related inquiries
As a result of offering such well-grounded, flexible services, we have been able to turn provider enrollment into a “launching pad” for providers to use in order to ensure regulatory compliance.
