Medicare EnrollmentByDr. Ron Short, DC, MCS-PWhy Enroll in Medicare?This is one of the most common questions that I am asked.You are required by law to to bill Medicare for covered services rendered to aMedicare beneficiary.You must be enrolled with Medicare as a provider to bill Medicare.The penaltyfor not billing Medicare for a covered service is up to 10,000 fine peroccurrence.They always start at 10,000.Additionally, the Medicare Program Integrity Manual, Chapter 15, Section 15.1States:“No provider or supplier shall receive payment for services furnished to aMedicare beneficiary unless the provider or supplier is enrolled in the Medicareprogram. Further, it is essential that each provider and supplier enroll with theappropriate Medicare fee-for-service contractor.”Steps to Enrolling in Medicare There are several steps in enrolling in Medicare.Each step requires completion before you can take the next step.Take these steps out of order and you will greatly prolong the enrollment process.Before you start the enrollment process you will need:o IRS documentation showing business name and taxpayer identificationnumbero State and/or local business license if applicableo State license to practiceo Physical Practice Locationo Practice Telephone Number You do not need to be in practice to begin theenrollment process.After you have the above information you will need to employ the followingforms.National Provider Identifier (NPI) ApplicationCMS-855IElectronic Data Interchange (EDI) Enrollment FormEDI Registration FormElectronic Funds Transfer (EFT) Authorization AgreementMedicare Participating Physician or Supplier AgreementCMS-855RCMS-855B You can treat Medicare patients up to 30 days prior to the officialreceipt of your application.

Your application is official on the date that it was received by the MAC and datestamped.According to Medicare Program Integrity Manual, Chapter 15, Section 15.17“In accordance with 42 CFR §424.520(d), the effective date for the individualsand organizations identified above (these include physicians and group practicesed.) is the later of the date of filing or the date they first began furnishing servicesat a new practice location.Note that the date of filing for Internet-based PECOS applications for theseindividuals and organizations is the date that the contractor received an electronicversion of the enrollment application and a signed certification statement.Because of this it is important that you send all application materials by certifiedmail with a return receipt requested.National Provider Identifier (NPI) The purpose of the NPI is to have a single universal identification number for allhealthcare providers in order to “improve the efficiency and effectiveness of theelectronic transmission of health information”. “Every provider that submits anenrollment application must furnish its NPI(s) in the applicable section(s) of theCMS-855.”“The provider need not submit a copy of the NPI notification it received from theNational Plan and Provider Enumeration System (NPPES) unless requested to doso by the contractor.”To obtain an NPI online go to process is straightforward and you should get your number by e-mailnotification in a few days.You can also submit the application on paper using form CMS-10114, but thiswill take longer to receive your number.There are two types of entityclassifications for NPIs:o Type 1: This classification is for individuals and sole proprietorships.Everyone needs a type 1 NPI and if you are a sole proprietorship, it is theonly NPI that you will need. Type 2: This classification is fororganizations. If you have a corporation or partnership, you will need atype 2 NPI also.CMS-855 Enrollment Form There are three CMS-855 enrollment forms that will concern the chiropractor.o CMS-855Io CMS-855Bo CMS-855RYou can submit these applications on paper.Or you can go to to accessthese applications and to access the internet-based PECOS system.

CMS-855I This form should be completed by individual practitioners, including physiciansand non-physician practitioners, who render Medicare Part B services to Medicarebeneficiaries. This includes a physician or practitioner who: (1) is the sole owner of aprofessional corporation, professional association, or limited liability company,and (2) will bill Medicare through this business entity. All doctors should enroll as individuals.CMS-855B This application should be completed by a supplier organization (e.g., ambulancecompany) that will bill Medicare for Part B services furnished to Medicarebeneficiaries.It is not used to enroll individuals. Any organization that will havemultiple owners (e.g., partnerships, corporations with multiple shareholders, etc.)should use this form to enroll the organization in Medicare.CMS-855R An individual who renders Medicare Part B services and seeks to reassign his orher benefits to an eligible entity should complete this form for each entity eligibleto receive reassigned benefits.The person must be enrolled in the Medicare program as an individual prior toreassigning his or her benefits. Your associate would use this form to reassign hisbilling rights to you.Also, any doctor working for an entity that would use the CMS-855B to enrollshould use this form to reassign their benefits to the entity.February 8, 2012 the OIG issued a special alert regarding form CMS-855R.Physicians who reassign their right to bill the Medicare program and receiveMedicare payments by executing the CMS-855R application may be liable forfalse claims submitted by entities to which they reassigned their Medicarebenefits.Even if someone else may be doing the billing, you are responsible to see that it isdone properly.Therefore, you must learn the procedures and periodically check to ensure thatthey are carried out properly.Avoid an associate contract that requires you to havenothing to do with the billing.You should know what the billing department is doing regarding claims forservices that you performed.The CMS-855R application must be completed for any individual who will (1)reassign his/her benefits to an eligible entity, or (2) terminate an existingreassignment.The CMS-855R and CMS-855I can be submitted concurrently.The effective date of a reassignment is the date on which the individual began orwill begin rendering services with the reassignee. Note that benefits arereassigned to a supplier, not to the practice location(s) of the supplier. As such,

the carrier shall not require each practitioner in a group to submit a CMS-855Reach time the group adds a practice location. If the individual is initiating areassignment, both he/she and the group’s authorized or delegated official mustsign section 4 of the CMS-855R.If the person or group is terminating a reassignment, either party may sign section4 of the CMS-855R; obtaining both signatures is not required. In situations wherethe supplier is both adding and terminating a reassignment, each transaction mustbe reported on a separate CMS-855R. The same CMS-855R cannot be used forboth transactions.CMS-855 Enrollment Form The contractors have deadlines that they are supposed to meet.The contractor is obligated to process 80% of paper-based applications within 60calendar days.They are obligated to process 90% of web-based applications within 45 calendardays. While the CMS-855 forms have thorough instructions and additionalassistance can be secured from your Medicare Administrative Contractor orCarrier, a few suggestions are:Have the following in hand prior to submitting anenrollment application; State professional license. Any required state or local business licenses. Documentation of Taxpayer Identification Number. Physical practice location. Practice telephone number.You may check only one reason forsubmittal of the application form. If you have more than one reason youmust submit multiple applications.o If you are enrolling for the first time, you may enter “pending” whenasked for your Medicare Identification Number.You may use a P.O.Box asyour correspondence address.o Solely owned practitioner organizations (professional corporation,professional association, or limited liability company) need only completethe CMS-855I application.o Sole proprietorships need not complete section 4A of the CMS-855Iapplication form.o Only the individual practitioner must sign the CMS-855I.CMS-588 Electronic Funds Transfer Form For new enrollees and revalidating providers, all payments must be made viaEFT.The contractor shall thus ensure that the provider has completed and signed theCMS-588.If an enrolled provider that currently receives paper checks submits aCMS-855 change request – no matter what the change involves – the providermust also submit:A CMS-588 that switches its payment mechanism to EFT. The change requestcannot be processed until the CMS-588 is submitted.

An updated section 4 that identifies the provider’s desired “special payments”address. Once a provider changes its method of payment from paper checks toEFT, it must continue using EFT. A provider cannot switch from EFT to paperchecks.The “special payment” includes payment of incentive bonuses for such thing aspracticing in a Healthcare Provider Shortage Area (HPSA).The “special payment” address may only be one of the following:o One of the provider’s practice locations.o A P.O.BoxThe provider’s billing agent.o The chain home office address.o Correspondence address Remember that electronic funds transfer worksboth ways.As part of the agreement you are agreeing to allow Medicare to deduct funds fromyour account if they should find that you have been overpaid. To limit this riskyou should open a separate account that is reserved just for EFT payments fromMedicare and keep only 100.00 in it.When a payment comes in withdraw all but the original 100.00. In this way, youlimit your risk of your account being raided.Par vs. Non-Par Much has been made about whether or not to be a participating provider.Some go so far as to state that you will not be reviewed if you are a non-parprovider.This is false.What does it actually mean to be a participating provider.Close examination of the Medicare Participating Physician or Supplier Agreement(Form CMS-460) indicates that you are agreeing to four things: That you willaccept assignment (direct payment to you instead of the beneficiary) on allMedicare claims filed for the calendar year.o That the Medicare approved charge for the service will be the full chargefor covered services.o That you will collect only the applicable deductible and coinsurance.o That the agreement will automatically renew annually unless you takespecific action to cancel it. In return for agreeing to this, Medicare willgive you some goodies.Among these are:o You are paid 5% more.o If you file electronically, you will receive your money within 2 weeks.o You will receive a Medicare Remittance Notice within a few days of beingpaid.o You are listed in the Provider Directory.o You are a party to a denial and, as such, you can initiate an appeal.o You can bill your full price to Medicare.o Claims are automatically forwarded to secondary insurance. If you do notparticipate, circumstances are a little different:o You are paid at 95% of the allowed fees.

o You can charge the patient up to the “limiting charge” which is set at115% of the allowed charge.o If you charge any amount over the limiting charge you risk a 10,000 peroccurrence fine. You are not listed in the Provider Directory.o You collect from the patient but, by law, you must submit claims anyway.o You can accept assignment, but it is on a claim-by-claim basis.o You will receive a Medicare Remittance Notice quarterly.o Under some circumstances you will not be able to initiate an appealwithout receiving an Assignment of Appeal Rights from the beneficiary.These requirements apply whether you elect to participate or not participate:o You are required to submit the claim for the patient.o You are subject to review by Medicare.o You are required to document medical necessity for all care for it to bepaid by Medicare. You are required to deliver an ABN to the patient whenyou believe that Medicare will not pay for the service.o You are required to adhere to all Medicare regulations. The only“advantage” to not participating is that you get to charge the Medicare patients15% more.This is offset by the fact that the Medicare patient is paying more out-of-pocketand will see your office as less desirable than the office that takes assignmentwhere they just walk-in, get adjusted, and walk out. Medicare wants you toparticipate because it is easier for them.Therefore, they will make it easier for you if you participate.Revalidation Per 42 CFR § 424.515, Medicare providers and suppliers (other than DMEPOSsuppliers) must resubmit and recertify the accuracy of their enrollmentinformation every five years in order to maintain Medicare billing privileged.Currently, most MACs are sending out revalidation letters.Per 42 CFR § 424.515,a provider whom the contractor requested to furnish all requested information (aspart of the revalidation) must do so within 60 calendar days after the date thecontractor notified the provider of the need to revalidate.If the provider fails to do so, the contractor shall revoke the providers billingprivileges using existing revocation procedures.The provider must submit allrequired documentation with its application, even if such documentation isalready on file with the contractor.There have been several cases of doctors ignoring revalidation letters and loosingtheir billing privileges.Changes to Medicare Enrollment On September 23, 2010 CMS published some proposed rules in the FederalRegister for comment.The comment period ended November 15, 2010.The final rules were published February 2, 2011.These rules were effective March 25, 2011.

The rules are as follows:Screenings to include: Verification of Medicare specific requirements. License verification. Database checks. Unscheduled/unannounced site visits. Criminal background checks. Fingerprinting.o There are three categories of screenings. Limited. Moderate. High.o “Physician and non-physician practitioners and medical groups andclinics” are to be placed in the limited category.The limited categoryincludes: “Verification of any provider/supplier specific requirementsestablished by Medicare.” “Conduct license verifications (may include licensure checksacross states)”. “Database Checks.” Database checks are: “to verify Social Security Number (SSN), theNational Provider Identifier (NPI), the National Practitioner DataBank (NPDB) licensure, an OIG exclusion, taxpayer identificationnumber, tax delinquency, death of an individual practitioner,owner, authorized official, delegated official, or supervisingphysician.”A specific provider type can be moved from “limited”category to “high” category.o For two reasons: If CMS believes that the specific provider type poses a greater riskof fraud, waste or abuse. If the specific provider type has been under a temporarymoratorium.o In the final rule Physical Therapists were moved from the “limited”category to the “moderate” category.Temporary moratoria on enrollmentof Medicare Providers and Suppliers, Medicaid and CHIP Providers. The Secretary of Health and Human Services may imposetemporary moratoria on the enrollment of new Medicare, Medicaidor CHIP providers and suppliers, including categories of providersand suppliers if the secretary determines such moratoria arenecessary to prevent or combat fraud, waste or abuse under theprograms.The moratorium will be imposed for 6 months andextended in 6 month increments as CMS deems necessary. The moratorium can be appealed through the DepartmentalAppeals Board level. Moratoria will be announced in the Federal Register and throughthe Medicare listserv.Suspension of payments.

CMS can suspend payments to a provider when there is a credibleallegation of fraud. CMS will consult with the OIG and/or the Department of Justice todetermine if there is a credible allegation of fraud.Application Fees For the purpose of the Affordable Care Act, CMS has determinedthat physicians are exempt from the payment of application fees.o If a provider or supplier is terminated from Medicare they will now beterminated from Medicaid and CHIP. It also works the other way. If a provider is terminated from Medicaid or CHIP then they willalso be terminated from Medicare.These provisions were effective March 25, 2011.They applied to new enrollees and revalidating enrollees at that time.They will apply to existing enrollees on March 25, 2012.Reportable Changes Once you are enrolled in Medicare, you are required to keep the Medicare carrierinformed as to changes in your status or information.The following changes are for individual physicians and can be reported on theCMD-855I form or on the PECOS online system. The following reportableevents are required to be reported as soon as possible but no later than 30days after the reportable event: Change in Practice Location Change in Final Adverse Action Physicians are required to reportthe following reportable events as soon as possible, but no later than 90days after the reportable event: Change of Business Structure. Change in Organization Legal Business Name/Tax IdentificationNumber. Change in Practice Status.o Other reportable changes include: Change in Reassignment of Benefits.o Change in Banking Arrangements or any Payment Information occurswhen a physician changes his or her bank or bank account or makes otherpayment information changes. This type of change should be reportedimmediately to the Medicare contractor. Physician group practices mustreport the following on the CMS-855B.o Physician group practices are required to report the following reportableevents as soon as possible, but no later than 30 days after the reportableevent: Change in Ownership or Managing Interest Control. Change in Practice Location. Change in Final Adverse Action.Physician group practices arerequired to report the following reportable events as soon as possible, butno later than 90 days after the reportable event:Change in Legal BusinessName/Tax Identification Number.

Change in Authorized or Delegated Officials. Change in Reassignment of Benefits.Change in BankingArrangements or any Payment Information occurs when a physician grouppractice changes its bank or bank account or makes other paymentinformation changes. This type of change should be reportedimmediately to the Medicare contractor. A physician group practice canupdate his or her electronic funds transfer information by submitting theElectronic Funds Transfer Authorization Agreement (CMS-588) to his orher Medicare Contractor.Opting Out of Medicare There is a procedure for physicians to opt out of Medicare and work privatecontract arrangements with their patients.Some consultants are currently sellingopt-out programs for chiropractors.The problem is that chiropractors cannot opt out of Medicare.Quoting Medicare Benefits Policy Manual, Chapter 15, section 40.4:For purposes of this provision, the term “physician” is limited to doctors ofmedicine; doctors of osteopathy; doctors of dental surgery or of dental medicine;doctors of podiatric medicine; and doctors of optometry who are legallyauthorized to practice dentistry, podiatry, optometry, medicine, or surgery by theState in which such function or action is performed; no other physicians mayopt out.Anyone promoting that there is a way for chiropractors to opt outMedicare is promoting something that, in all probability, will get doctors introuble.

Medicare Enrollment By Dr. Ron Short, DC, MCS-P Why Enroll in Medicare?This is one of the most common questions that I am asked. You are required by law to to bill Medicare for covered services rendered to a Medicare beneficiary. You must be enrolled with Medicare as a provid