The new health reform law includes several provisions that impact both Medicare and Medicaid enrollment.
Under the law, the Centers for Medicare and Medicaid Services (CMS) must expand the current Medicare provider enrollment process to include additional methods of screening practitioners starting in 2011. Under the law, CMS is required to conduct licensure checks and is permitted to conduct criminal background checks, fingerprinting, unscheduled and unannounced site visits, and other mechanisms that can be used to screen potential providers of Medicare services for fraudulent or otherwise criminal behavior. While originally, the law also required the collection of an application fee for both individual and institutional providers, such as hospitals or skilled nursing facilities, the fee is no longer required for individual providers. Currently enrolled practitioners making changes to their enrollment application will be subject to the new screening process beginning in 2012.
The new health reform law also permits CMS to require certain sectors or categories of enrolled providers to establish compliance programs as a condition of Medicare enrollment. CMS will be required to determine the core elements of such a compliance program. CMS will also be allowed to establish temporary moratoria on the enrollment of different provider types if it determines that it is necessary to combat fraud and abuse.
The law also dictates that these new measures be included as part of provider enrollment in state Medicaid programs. In addition to the requirements detailed above, state Medicaid programs must also require that ordering and referring physicians be enrolled in their program and that the National Provider Identifier (NPI) of ordering or referring physicians be included on claims. This is a new requirement for the Medicaid program and states will need to revise their provider agreement processes to collect this information.
CMS in May released an interim final rule on Medicare and Medicaid provider enrollment that addresses these NPI requirements. Under the rule, all practitioners enrolling in the Medicare or Medicaid programs as of July 6 must include their NPI in their application materials. NPIs must also be included on all Medicare and Medicaid claims, along with the ordering or referring practitioner’s legal name.
The ACC recommends that members ensure their Medicare provider enrollment information is current and accurate. If it is not, enrollment applications should be submitted as soon as possible, but certainly by July 6 (see related article on new ordering and referring policies). Practitioners that enrolled in Medicare prior to 2003 and who have not updated enrollment records since that time are likely not to have an enrollment record in the Medicare provider enrollment database. To ensure that one is created, a Medicare provider enrollment application (CMS-855 form) must be completed. Medicare contractors are reported to be experiencing higher than normal volumes of Medicare provider enrollment application submissions as a result of the new changes. Please contact the ACC if you experience sustained delays of six months or more.
To read the cardiovascular community's formal comment letter sent June 9 to CMS on the interim final rule, click here.