What do the new Medicare retroactive billing guidelines mean for hospitalists and new practices. Medicare is always the most convaluted aspect of credentialing because of the red tape and time required to credential a new physician or group. It is important that you understand how important it is that you have experts complete your applications because it could cost you thousands of dollars in missed opportunities to bill for services or in denied claims.
Here is an article from the AMA:
Medicare Enrollment Process
The Medicare enrollment process is a critical area of the program as it serves as the gateway into the program. Before physicians can bill Medicare they must submit an enrollment application to their Medicare contractor and have it successfully processed. Unfortunately, there have been significant problems with the Medicare enrollment process over the past several years, a situation that has been seriously exacerbated by the transition to the National Provider Identifier (NPI) number and the transition from Medicare carriers to Medicare Administrative Contractors (MACs). CMS made significant changes to the enrollment process in the spring of 2006 and since then has continued to modify the process. Problems with the Medicare enrollment process, however, precede even 2006 and the AMA has long championed (PDF) streamlining this process.
Among the changes Medicare made to the enrollment process in 2006 was the requirement that physicians obtain their NPI prior to enrolling or making a change to their enrollment information. Due to the complexity of the Medicare program and their inability to effectively match a physician’s new NPI number to their old billing number internally, several physicians experienced claims processing interruptions following physician use of this new number. Leading up to and following the May 23, 2008 NPI compliance deadline, Medicare’s solution to this problem was to require many physicians nationwide to re-enroll, even physicians who had been in the Medicare program for decades. This placed an extreme burden on an already severely taxed system because many Medicare contractors experienced spikes in the number of enrollment applications submitted. The end result, which continues in some cases today, are enrollment backlogs and very long delays for physicians to get their applications processed.
Most recently, Medicare made further sweeping changes to the enrollment process that were effective January 1, 2009. Due to significant advocacy by the AMA, Medicare postponed many changes until April 1, 2009. The AMA together with the Medical Group Management Association (MGMA) have developed a toolkit for members (PDF) describing these changes and steps physicians can take help ensure a smooth enrollment process.
Changes to the Medicare Enrollment And Billing Process
Despite repeated protests by the AMA, state, and specialty medical societies, Medicare has indicated has made further sweeping changes to the enrollment and billing process. The AMA has advocated strongly against making any more changes to the enrollment process that could further jeopardize the already fragile process. Two of the most problematic changes that physicians need to be aware of involve new timeframes for reporting changes to Medicare enrollment information and a new, shorter retroactive billing period.
First, physicians who have experienced a change in practice location, a change in ownership or financial or controlling interest, or and adverse legal action are required to report these changes within 30 days. All other changes must be made within 90 days. If physicians do not adhere to these timeframes, they could lose their billing privileges for at least a year if a Medicare contractor learns the changes have been made. The AMA continues to oppose and advocate against the 30-day timeframe as it is too short.
Second, prior to January 2009, Medicare permitted physicians to submit claims as far back as 27 months. However, under new rules, Medicare will only allow physicians who are enrolling in Medicare to bill back as far as 30 days prior to the date their application is considered “effective.”
For physicians this means under the new regulations, you are only permitted to bill Medicare for services furnished to Medicare patients up to 30 days before your billing effective date. The effective date is the later of:
- The date you filed an application that your Medicare contractor ultimately approves; or
- The date you began furnishing services at a new practice location.
Your “filing” date is defined as the date your Medicare contractor receives your approvable Medicare enrollment application. In the case of an application submitted using Internet-based PECOS, the filing date is the date the contractor receives all of the following:
- Your electronic enrollment application; and
- Your signed certification statement that is signed with an original signature and mailed to your Medicare contractor.
The AMA has been successful in getting CMS to postpone the implementation of this change from January 1, 2009 until April 1, 2009 in order to ensure enrollment backlogs are reduced. For a complete list of changes to the Medicare enrollment process please visit the enrollment toolkit for members (PDF). For more information on changes to the retroactive billing period, review the section of the toolkit titled, “2009 Changes to Medicare Provider Enrollment.”
