Medicare Provider Enrollment

Transcription

1 Medicare Provider Enrollment Center for Program Integrity Centers for Medicare & Medicaid Services Zabeen Chong Director, Provider Enrollment Oversight Group Charles Schalm Deputy Director, Provider Enrollment Oversight Group Richard Gilbert Director, Division of Enrollment Systems Decision Health April 28, 2015

2 A Behind the Scenes Look! Understanding the Enrollment Process Things to Know Before Completing your Enrollment Application Policy Changes Provider Enrollment Initiatives Medicaid Data Sharing Sneak Peek Into the Future 2

3 Understanding the Enrollment Process 3

4 Lifecycle of an Enrollment Application 1 Application Submission to MACs CMS 855 Form MAC Mail Room & Data Entry 6 7 Claims Systems (pays claims) MAC updates claim system (1-2 days) Provider not approved until claim system updated 2 3 MAC Recommendation to State /RO Medicare Providers & Suppliers (w/npi) Online PECOS Development Letter 5 Enrollment Screening and Verification Prescreening Process: Signed/Dated Required data elements App fee/waiver Supporting docs 4 Data Verification Ex: LBN SSN NPPES Address License Adverse Actions Certified Providers/Suppliers 3-9 months or longer 1. Application Submission by Provider 2. Application Receipt and Data Entry into PECOS (Paper Only) 3. Application Receipt and Data Insertion in PECOS (Online Only). MAC not required to rekey data 4. Enrollment Screening and Data Verification Processes (not inclusive) 5. Develop for missing information (paper and web) 6. Data Transfer 7. Data Finalization 4

5 Application Processing Times MACs target these processing times.. Online PECOS Initials and changes of information processed within 45 days (timeframe based on complete electronic process - e- signature, digital upload, etc.) Initials and changes of information processed within 60 days PECOS the fastest way to submit your enrollment application Visit the PECOS homepage s.gov/pecos/login.do for helpful information CMS 855 Form * Timeframes based on a clean application with no required site visit. But delays occur when.. 5

6 Application Development Non-response to development results in: Delays in application processing Application rejections Delays in effective date Biggest delay in application processing Approximately 30-35% of applications require 1 or more rounds of corrections Most Common Reasons for Development: Missing documentation (IRS documents, CMS 588 EFT, voided check, bank letter, education documentation) (web and paper) Missing fields (Medicare IDs when revalidating or establishing new reassignment, section 5/6) (paper) Missing signature/date or incorrect signer on certification statement (paper) Incorrect form/ outdated version submitted (855A vs 855B) (paper) Legal Name and Legal Business Name (LBN) mismatches in NPPES (web) 6

7 Data Verification Automated Personal Information - SSA validation (Name, DOB, SSN) integrated in PECOS Practice Location - Address verification (integrated in PECOS), site visit OIG Exclusion List - Monthly systematic checks in PECOS Deceased Providers or Associates - Death Master File (DMF) NPI and Legal Business Name (LBN) - Validated through NPPES Manual Legal Business Name - CP-575 or other IRS documentation License - State licensing board websites, license documentation, monthly website checks, monitored alerts Exclusion and Debarment Lists OIG and GSA websites Adverse Legal History State licensing board 7

8 Who Does the MAC Contact? When the MAC has an issue validating enrollment data or needs to develop for missing information they contact.. Contact Person (Section 13) Individual Provider (Section 2) or AO/DO of Organization (Section 15/16) /fax preferred method of contact, then phone First POC is always the contact person listed in Section 13 If multiple contacts listed, MAC selects which individual to contact unless provider indicates otherwise 8

9 Method of MAC Contact Development letter sent to contact person, individual provider or AO/DO identifying missing data/documentation Provider given 30 days to respond * Preferred method of contact is /fax Web Paper generated from PECOS Sent to contact person in PECOS Sent to contact person address or correspondence address Fax Mail 9

10 Things to Know Before Completing Your Application 10

11 Authorized Official Must possess an SSN Multiple AOs permitted Official with the authority to enroll and make changes to an organization s enrollment information. Responsible for maintaining compliance CEO, CFO, general partner, chairman, owner CMS-855A, 855B, 855S initial applications must be signed by an AO (physician can only sign the 855I) Able to sign web (e-sign) and paper applications 11

12 Delegated Official Must posses an SSN DOs are optional Multiple DOs are permitted Individual appointed by the AO with authority to report changes to enrollment information Individual with ownership or control interest in, or a W-2 managing employee of provider/supplier Can sign changes of information and revalidation applications Able to sign web (e-sign) and paper applications 12

13 Managing Employee General manager, business manager, administrator, director Authorized by the AO or DO to handle dayto-day operations All managing employees need to be listed in Section 6 of the Form CMS-855A or CMS- 855B (At least one is required) Can be contracted or a W-2 employee Can also be an AO if maintains another role in section 6 (owner, partner, director, officer) Cannot sign web (e-sign) or paper applications 13

14 Medicare Effective Dates: Part B Part B (physicians, non-physicians, group practices) Application received Jul 1, 2015 Effective date is the later of: File date of an application that was subsequently approved First begin furnishing services at a new location 30 day retro effective date permitted Mar Apr May Jun Jul Aug Sept Applications may be submitted 60 days prior to the effective date Effective date is Jun 1, 2015 (30 days prior to application receipt date) Application approved Aug 5, 2015 MACs have 60 days to process Must be in compliance at requested effective date (operational, licensed) 14

15 Medicare Effective Dates: Part A Part A (hospitals, HHAs, SNFs) Application received May 15, 2015 MAC recommends approval to RO Jul 15, 2015 RO approves Sept 15, 2015 and establishes effective date Feb Mar Apr May Jun Jul Aug Sept Oct Applications may be submitted 180 days prior to the effective date Effective date is based on: Completion of survey Regional Office (RO) determines all requirements have been met Effective date is Jun 1, 2015 (Provider determined to be in compliance) MACs have 60 days to process and make a recommendation to the state/ro Must be in compliance at requested effective date (operational, licensed) 15

16 Reporting Changes of Information Changes in ownership, adverse legal action, and practice locations must be reported within 30 days. All other changes in enrollment must be reported in 90 days All changes must be reported to your MAC Failure to report a change in information may result in the revocation of your Medicare billing privileges Notifying the state, Regional Office, or another agency of a change of information does not meet the Medicare enrollment reporting requirements and may lead to deactivation/revocation 16

17 What Numbers Do I Need? Medicare Enrollment Report Enrollment ID - Helps the MAC find information about a particular enrollment record in PECOS NPI or Medicare ID Helps MAC find information on an enrollment record or claim information in claims system 17

18 What Numbers Do I Need? Medicare Enrollment Report Web Tracking ID Helps the MAC identify a particular application submitted through PECOS. 18

19 Policy Changes 19

20 Processing Improvements Allow MACs to validate blank data/checkboxes (reason for application submission, business structure, Medicare IDs, add/edit/delete actions) through , telephone, fax Utilize missing information disclosed elsewhere on the application or in supporting documentation Accept fax information (supporting documentation) Verify education requirements online 20

21 Processing Improvements Suggest 855I and 855R applications submitted together be processed by the same analyst Copy of driver s license/passport no longer required to validate signature Permit MACs to validate multiple practice locations with the contact person vs. contacting each location separately Accept photocopied pages of the CMS 855 (i.e., all 5% owners the same across multiple applications, photocopy section 5/6). Note: Must accompany an original signature 21

22 Provider Enrollment Initiatives 22

23 Revalidation All 1.5M revalidation notices mailed by the March 23, 2015 deadline We couldn t have succeeded without your efforts and feedback. THANK YOU! CMS to begin Cycle 2 to resume regular revalidation cycles (every 3 years for DME suppliers and every 5 years for all other providers suppliers) Suggestions for Cycle 2. Provide revalidation notices through published lists on CMS.gov six months prior to revalidation due date (no mailed letters) Eliminate multiple phone calls prior to deactivation Send one notification prior to deactivation for non-response (30 days in advance) Deactivate after 120 days from the published list if no response Deactivate instead of revoke if no response Large group coordination (notify groups when providers linked to their group have been selected to revalidate) 23

24 Fingerprint Based Background Checks Fingerprint-based background checks implemented on August 6, 2014 Impacts newly enrolling DME suppliers, HHA and providers/suppliers elevated to high risk Check the status of your fingerprints at ting.com Required on all individuals with a 5% or greater ownership interest in a provider/supplier in the high risk category Rolled out in a phased approach MACs will notify applicable providers/suppliers via letter Providers/suppliers given 30 days to be fingerprinted Fingerprint instructions and locations are included in the letter and available online Criminal activity found could result in denial of enrollment application or revocation of existing Medicare billing privileges SE1417 Implementation of Fingerprint-Based Background Checks 24

25 Prescriber Enrollment Requirements Aids CMS efforts to combat part D fraud and abuse CMS has announced a delayed enforcement until December 1, 2015 Top 5 impacted specialties: Dentists Interns/residents Nurse Practitioners Internal Medicine Family Medicine CMS-4159, published on May 23, 2014, gives CMS the authority to: Require physicians and other eligible professionals who write prescriptions for Part D drugs to: Be enrolled in Medicare in an approved status Definitive list of providers eligible to prescribe available at List/u8u9-2upx Updated every 2 weeks with a goal to increase frequency of file to twice a week 25

26 Prescriber Enrollment Requirements Medicare Administrative Contractor (MAC) Guidance Anticipate 855I, 855O and opt out submissions Educate staff and customer service analyst to avoid misinformation Require CMS approval prior to returning/rejecting applications from dental providers Prioritize applications 6 months before enforcement Outreach to Prescribers, Plan Sponsors, and Enrollees Target unenrolled prescribers through messaging, FAQs, MLN articles, dedicated prescriber enrollment website, enrollment tutorials, digital ad campaign Direct outreach to groups/associations (PCMA, ADA, AMA, MGMA) Update customer service representatives scripts at Medicare; Medicare & You Handbook 26

27 Medicaid Data Sharing 27

28 Information Sharing w/ Medicaid Enrollment Data: Provider enrollment information on file with Medicare and effective date of enrollment Site Visit Information: Date and results of site visits Payment Information: Application fees paid and hardship waiver information Fingerprint Information: Date and results of fingerprint 28

29 Sneak Peak into the Future 29

30 PECOS in 2015 Communication/Efficiency Review and update NPI records as part of enrollment submission Include additional information on s (NPI/Medicare ID) Supporting Document Enhancements Sort Data in Alphabetical Order Fixing Issues Preventing Online Applications: Edit Legal Business Name & Individual Name Update Primary Specialty Edit Chain Home Office Administrator Remove Date Restrictions for Incorporation and TIN Effective Dates Exclude Part B Hospital Departments from Application Fee Requirement Changes that are not scheduled, yet: Change in Tax ID Number Business Structure

31 NPPES Modernization 4.1 Million Active NPIs used in nearly all Healthcare transactions. 31% 12,000 Records Updated/Month 2,000 Downloads/Month Individuals Organizations 69% 25,000 New NPIs Issued/Month Issues Facing NPPES: Data Accuracy - No incentive for providers to update information, resulting in outdated address and license data Underlying Technology Costly and complex system architecture result in slow changes Usability & Accessibility - Updates can only be made 1-by-1 via time consuming website or paper application 31

32 Our Approach to Modernizing NPPES Engage with community to determine the needs and wants from the provider community, and why there was a lack of engagement Evaluate Operational, Policy, and System Changes that would motivate providers, and/or improve operations Make It Tangible - Create visual prototype that represented features and changes requested by the community and stakeholders Develop sustained improvement plan that would continue beyond the initial roll out 32

33 The Future of NPPES New Features and Operational Changes to Increase Relevance to Community New Registry w/direct Data Connectivity Link to PECOS Additional Data Alerts Intuitive and Mobile Ready Website Design Bulk Management by Surrogates 33

34 Wrap Up! We hear you, learned a lot from you, and are improving customer service and processing guidance to help. We believe Provider Enrollment MUST be easy for good providers, and hard for the bad. We are continuing to make changes to improve access to information and tools through PECOS. 34

35 Helpful Contact Information EHR Website: Information Center Help Desk: (888) Provider Enrollment Mailbox: Medicaid Provider Enrollment Inquiries: Survey and Certification Contacts: Enrollment-and-Certification/SurveyCertificationGenInfo/ContactInformation.html 35

36 Proactive Education & Outreach List Serv - Notification of program and policy details, updates and announcements, press releases, event reminders, educational material announcements, and other news and information for Medicare Fee For Service (FFS) providers. To join send an to FFSProviderRelations@cms.hhs.gov CMS.gov Access to data like Revalidation, Ordering and Referring, and DMEPOS Accreditation and Supplier Standards. PECOS Homepage - Redesigned to have quick links to account creation, video tutorials, providers resources, and FAQs. Medicare Learning Network MLN Matters Articles Articles designed to inform providers about the latest changes to the Medicare Program. To sign up for MLN Matters notifications go to CMS.gov and search: MLN Matters. National Provider Calls - educational conference calls conducted for the provider community that educate and inform participants about new policies and/or changes to the Medicare program. 36

37 Thank You Zabeen Chong Director, Provider Enrollment Oversight Group Charles Schalm Deputy Director, Provider Enrollment Oversight Group Richard Gilbert Director, Division of Enrollment Systems Center for Program Integrity Centers for Medicare & Medicaid Services 37

38 Disclaimer This presentation was current at the time it was published or uploaded onto the web. Medicaid and Medicare policies change frequently so links to the source documents have been provided within the document for your reference. This presentation was prepared as a service to the public and is not intended to grant rights or impose obligations. This presentation may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. Use of this material is voluntary. Inclusion of a link does not constitute CMS endorsement of the material. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents. Presentation Date: April 28,