Medicare Compliance & Reimbursement

Get the facts on Medicare enrollment appeals.

Whether you’re new to Medicare or have been a provider in the system for years, the enrollment process is complicated — and the pandemic has only added confusion to the system. From form updates to revalidation letters to the oft-changed billing rules, there is a lot to know to ensure that both your Medicare provider enrollment and payments remain steady and secure.

Review these Medicare enrollment commonly-held ideas to see how your knowledge stacks up against the facts.

1. True or false: There’s no situation in which an individual provider would ever need more than one National Provider Identifier (NPI).

False. First, remember that you need an NPI before enrolling as a Medicare provider. This 10-digit number identifies you to all payers and signals that you are a HIPAA-covered provider.

There are two NPI types, and depending on the classification particulars, a provider might need two different NPIs.

Type 1 refers specifically to individual providers like physicians, dentists, or sole proprietors, indicates the Centers for Medicare & Medicaid Services (CMS) in online guidance.

Type 2 concerns organizations like hospitals, physician practices, or nursing facilities. Corporations also fall under Type 2, and herein lies the double NPI caveat. “If you are an individual who is a health care provider and who is incorporated, you may need to obtain an NPI for yourself (Type 1) and an NPI for your corporation or LLC (Type 2),” notes CMS guidance.

2. True or false: Providers can have their Medicare provider enrollment denied with zero recourse.

False. There’s actually an appeals process for practitioners who contest their Medicare enrollment decisions. “Providers who disagree with a provider enrollment determination may appeal the decision by submitting a corrective action plan (CAP) and/ or a reconsideration request,” notes Part B MAC WPS-GHA in online guidance.

If you choose to send a CAP in response to your denial or revocation letter, you have 35 days to submit it from the initial determination. Plus, you need to send a letter signed and dated by the provider or authorized official — and the letter and CAP must explain in detail how the practitioner is fully in compliance with Medicare requirements, advises WPS-GHA.

Important: An “authorized official” must be appointed by the organization and have legal authority to deal with Medicare enrollment matters.

You can also ask for a reconsideration, which is traditionally performed by a hearing officer through your MAC. “This independent review is conducted by a person who was not involved in the initial determination,” explains the Part B MAC. However, providers need to send their requests and additional documentation within 65 days of the initial determination — or the MAC considers the provider’s rights to a review waived, WPS-GHA warns.

3. True or false: CMS paused revalidation efforts during the public health emergency (PHE).

True. “During the COVID-19 PHE, CMS will not issue any new revalidation notices, deactivate providers who fail to respond to revalidation requests, or update the Medicare Revalidation Tool at https://data.cms.gov/revalidation  with new revalidation due dates,” notes agency guidance.

However, that doesn’t mean that the MACs have stopped Medicare enrollment renewals altogether. “Revalidation applications submitted to your MAC will continue to be processed but not in an expedited manner,” says consulting firm The Health Group in Morgantown, West Virginia, in its electronic newsletter.

Reminder: Revalidation is CMS’ official term for renewing your provider enrollment, so you can continue to bill Medicare. Providers and suppliers must revalidate every five years while DMEPOS suppliers are required to renew every three years. “CMS also reserves the right to request off-cycle revalidations,” reminds agency guidance.

4. True or false: Locum tenen physicians cannot be used to cover for deceased Medicare providers.

True. CMS receives a monthly death report from the Social Security Administration (SSA), which is used to identify Medicare providers who’ve died. The agency then uses the data and deactivates individual providers’ enrollments in Provider Enrollment, Chain, and Ownership System (PECOS), using the date of death as the deactivation date, according to Part B MAC Noridian’s online guidance.

Details: The reason that locum tenens cannot be hired for deceased physicians is quite simple. The deceased provider’s Type 1 NPI and provider transaction access number (PTAN) are deactivated by CMS after the agency gets the report; therefore, the temporary physician has no NPI to bill Medicare under.

“All claims submitted after the date of death using the deceased providers Type 1 NPI will NOT be paid,” Noridian exhorts.