Understanding Medicare Corrective Action Plans

For Medicare enrollees denied enrollment or current providers or suppliers that had billing privileges revoked, CMS established the option to file a Corrective Action Plan (CAP). Filing a CAP provides the opportunity to “correct” the deficiencies that resulted in the denial or revocation.

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Don’t Hesitate — Revalidate

Revalidation efforts are underway again, but this time for all providers and suppliers. When CMS revised the Medicare enrollment rules in June 2006, one change was to require each provider or supplier to revalidate its enrollment at least every 5 years. The initial revalidation efforts, which began in 2007, focused on providers and suppliers that had enrolled prior to 2003, when CMS had fully implemented the PECOS database for maintaining Medicare enrollment data. This article contains information on the revalidation process and tips for preparing revalidation forms.

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Application Fees

To help offset the costs of the screening required under the program safeguard rules for Medicare-enrolled providers and suppliers, an application fee was implemented.   With the annual update factor, the current fee for $505.00 for 2011 and $523.00 for 2012.

Application fees are assessed at the time of the initial Medicare enrollment, when a practice location is added, and when responding to a revalidation request.  With the exception of individuals (physicians and non-physicians practitioners) and group practices, all other providers and suppliers are assessed the application fee.

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Ordering and Referring Practitioner Enrollment Form

CMS recently developed a new enrollment form — the CMS 855O form — which would allow a physician or non-physician practitioner (NPP) who otherwise does not need to have Medicare billing privileges, to submit an application to obtain an enrollment record in PECOS.

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Webinar Focusing on Medicare and Medicaid Enrollment Requirements

On April 27th I presented a webinar on the recently released Medicare and Medicaid enrollment rules.

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New Medicare and Medicaid Enrollment Rules Take Effect Today

Significant changes effecting Medicare- and Medicaid-enrolled providers and suppliers take effect today, March 25, 2011.  The new regulations are in response to provisions in the recent health care reform legislation designed to enhance the enrollment procedures to protect against fraud.  All Medicare-enrolled providers and suppliers were grouped into one of three categories “limited,” “moderate,” or “high” risk, with delineated enrollment screening procedures for each category.  The greater the perceived risk of fraud, the more scrutiny for the applicant or enrollee.

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60-Day Comment Period for New Medicare and Medicaid Enrollment Rules Ends November 16, 2010

Do not lose this opportunity to submit comments to the proposed changes in the Medicare and Medicaid enrollment rules, whether submitted individually or in conjunction with professional or trade associations.

Enrollment screening procedures would be increasing more rigorous based upon the provider’s or supplier’s placement into the “limited,” “moderate,” or “high” risk category.

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Are You Compliant With New DMEPOS Supplier Standards?

The final August 27, 2010 regulations apply to hospitals, skilled nursing facilities, and home health agencies that have additionally enrolled as a DMEPOS supplier and not just free-standing DMEPOS suppliers. Learn more about these new regulations in my article “DMEPOS Suppliers Beware – Operational Changes May Be Required to Avoid Revocation” written for the Ober Payment Matters publication.

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Site Verifications – Would Your Practice Location Pass?

As part of the overhaul of the enrollment rules in June 2006, CMS adopted new regulations under 42 C.F.R. § 424.510(d)(8) authorizing on-site reviews to determine if an enrolled provider or supplier is “operational” to furnish Medicare covered items or services and whether or not the provider or supplier is in compliance with the Medicare enrollment requirements. These site verifications are in addition to on-site surveys performed for determining compliance with the conditions of participation for Medicare-certified providers and suppliers.

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Medicare Enrolled Providers – Is Your PECOS Data Current?

Sanctions for Failure to Provide Timely Updates

Although Medicare-enrolled providers and suppliers historically were required to provide notice of changes in enrollment data, prior to the Medicare enrollment rule changes in June 2006, there were no sanctions for failing to do so. Effective June 2006, CMS changed its rules to allow the imposition of sanctions for failing to provide timely notification of changes in enrollment data. With sanctions now in place, it is important for enrolled providers and suppliers to understand the duty to report changes in enrollment information and the time frames for reporting such changes.

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