Hospital Payment Delays for Unreported Practice Locations

The revalidation process and increased sanctions for non-compliance with the requirements to update Medicare enrollment has not succeeded in ensuring all providers understand the importance of having accurate Medicare enrollment data. And, some providers mistakenly believe that all of the provider’s practice locations must have been reported since claims were being paid.  CMS’ historic purposeful separation between Medicare enrollment data in PECOS and claims data in FISS facilitated that misunderstanding.  Effective as of January 1, 2017, that will change.

To accommodate changing payment policies for off-campus outpatient hospital departments, CMS created an interchange between the PECOS and FISS software systems. For any claims submitted after January 1, 2017, CMS has instructed its MACs to return the claim to the provider (RTP’d) until the hospital obtains an approved CMS 855A update to report the previously unreported location.

It would be easy to have missed this change, since CMS only recently announced its policy update and placed it in the One-Time Notification manual via Transmittal 1704.  And, the accompanying short MLNMatters MM9613 publication had a title, “Implementing Provider File Updates and PECOS to FISS Interface Via Extract File Updates to Accommodate Section 603 Bipartisan Budget Act of 2015,“ which was not likely to encourage someone to read further.