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Medicare Final Rule on Establishing and Maintaining Enrollment

Posted by: Robert Markette
May 08, 2006

I have been a little sporadic in my posts the last week.  That was in part due to speaking at the Indiana Association for Home and Hospice Care’s annual conference.  I spoke on Tuesday and Thursday, which made Wednesday and Friday rather hectic at the office.

As promised two weeks ago, I read the Medicare final rule on Establishing and maintaining Medicare Billing Privileges.  It was published on April 21, 2006.  It is effective June 20, 2006.

The rule covers enrolling as a provider, denial of enrollment, and revocation of enrollment.  In most respects, the rule reflects how enrollment has been handled by manual and memo for years.  The rule does add a requirement for the resubmission and recertification of enrollment information.

The rule requires providers to resubmit and recertify the accuracy of their enrollment information every five years in order to maintain their Medicare billing privileges.  The rule states that all providers who are currently billing the Medicare program are required to complete the applicable enrollment application.  Providers will then be placed into the five year revalidation cycle.  In the comments, CMS states that they will contact currently enrolled providers to let them know when their revalidation cycle starts.  

The rule states that CMS will contact each provider when it is time to recertify.  The provider will then have sixty days to respond to the request.  Of course, although the rule requires resubmission every five years, CMS specifically reserves the right to perform “off-cycle” resubmissions

According to the rule, off-cycle resubmissions may be triggered by a number of factors.  These factors include complaints, national initiatives and suspicions of local health fraud, amongst other things.

The rule states that you will not have to have an additional survey as part of the “resubmission.”  You will also not have to complete a new provider agreement.  CMS may perform an “on-site inspection” to confirm your submission.  This may sound like a survey, but it strikes me that adding another survey (especially for those of you who are surveyed annually for licensure and certification) would be burdensome for CMS, states, and providers.

CMS states in the comments that the resubmission is necessary for a number of reasons.  Primarily, CMS is hoping that this resubmission will help them identify entities that are billing Medicare inappropriately.  In the comments to the final rule, CMS states that the revalidation process will “further ensure that Medicare beneficiaries are receiving services furnished only by legitimate providers.”  Its funny, I figured the annual survey accomplished that just fine.  Anyways, you should be awaiting notification from CMS that your five year period had begun.  I assume that when you receive this notification you will have sixty days to respond with the appropriate enrollment information.


         

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