Medicare for Geeks
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.
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.
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.
A recurring theme of this Blog will be to highlight various initiatives undertaken by CMS to tighten the Medicare enrollment rules in an attempt to combat fraud and abuse. Fueling one of the initiatives is CMS’ concern that historically providers and suppliers with questionable qualifications have been allowed to enroll in Medicare. To address this concern, CMS determined it is necessary to ensure that physicians and other eligible professionals who order, refer or furnish certain items or services have an approved enrollment record in the Provider Enrollment, Chain and Ownership System (“PECOS”). Items and services that require an order or referral include home health, laboratory, imaging, DMEPOS, and specialist services. It is critical to understand the effect of this initiative, especially the implications for suppliers that simply render services in response to an order or referral from a physician or non-physician practitioner who fails to comply.
Many physicians, non-physician practitioners, and other suppliers are losing revenue for failing to update credentialing and enrollment policies and procedures to account for the change in the Medicare enrollment rules. Under the prior rules, upon successful completing of the Medicare enrollment process, a supplier (which includes individual practitioners and practitioner groups) could bill for services that had already been provided, so long as the time period for filing a claim had not expired.
PECOS, the Provider Enrollment, Chain, and Ownership System, is a national electronic database for recording and retaining data on Medicare-enrolled providers and suppliers. CMS developed PECOS as a mechanism to combat fraud and abuse. When it proposed its plan to launch the use of the PECOS database in October 2001, CMS announced “it will now be possible to link providers/suppliers to the people and organizations with which they have a business relationship and to identify those involved in illegal Medicare activities.”