Details, details, details—it’s all in the details.
Even among long-term practitioners, there is still a great deal of confusion about the Medicare enrollment and revalidation process.
Where the enrollment process begins
Doctors of chiropractic should know that they must enroll with Medicare if they wish to deliver manual manipulations to a Medicare patient. Unfortunately, there are some who are still not aware of this, so note that absolutely no manual manipulation can be performed on a Medicare patient without first enrolling with Medicare or completing a successful revalidation. As part of enrollment, you are required to have an active Provider Transaction Access Number (PTAN) to provide and bill for services.
The enrollment process, whether by paper or electronically, can be daunting. The first steps may seem obvious but one must be a licensed physician or qualified non-physician to enroll. There are 15 non-physician entity types.
Each provider must have an individual National Provider Identifier (NPI) number. If you are a provider running your own practice, which should have a state appointed Tax ID number, your clinic will also need to have an NPI number. Both are established through the National Plan and Provider Enumeration System (NPPES) website.
As part of the NPI enrollment process, you create a username and password through the NPPES website. If enrolling with Medicare through the electronic portal (Provider Enrollment, Chain and Ownership System, also known as PECOS), the same username and password set up through NPPES will be used to access information in PECOS. This is because Medicare verifies the information you provide to them with what is contained in NPPES. Medicare currently prefers that all enrollments be performed through the PECOS system as it’s faster and more accurate.
Paper enrollment, multiple forms
If enrolling by paper, secure the following forms as needed from the Centers for Medicare and Medicaid Services (CMS) website:
- CMS-855I: Individual Physicians or Non-Physicians (the provider)
- CMS-855B: Clinics/Group Practices and Certain Other Suppliers (the office)
- CMS-588: Electronic Funds Transfer Form (EFT)
- CMS-460: Medicare Participating Physician or Supplier Agreement
- CMS-855R: Reassignment of Medicare Benefits
From the list above, if you wish to enroll with Medicare, you will have to provide one or more (or in some cases all) of the forms, either by paper or electronically. If submitting through the PECOS system, know that it does not provide the designated form numbers on the portal. Rather, a series of questions will determine which forms should be submitted based on the answers you provide.
Additional documentation for verification purposes
During enrollment, Medicare will request additional documents to verify your identity. As an individual provider, you can use a Social Security number in place of a Tax ID number and taxonomy codes. Although, given the risk of identity theft, some providers choose to acquire a Tax ID number to associate them as an individual. If also enrolling a clinic, a state-issued Tax ID number for that entity is also necessary.
There are several scenarios when it comes to applying for and selecting a business entity type, including LLC, Inc, PA, PC, and PLLC. Seek advice from an accountant, attorney or business adviser to determine your best choice. Your Medicare enrollment is directly tied to the Tax ID number established for your business. When Medicare and other carriers send W-9 forms in January each year, this information is used to file the taxes for the provider or the clinic from the preceding year.
Whether for an individual or a group clinic, your Tax ID information is a required document to send with your application. This document will be a CP575 or a 147C (either one is acceptable).
Other documents that are required for enrollment are a copy of your physician license, business license (if required in your state), and malpractice coverage. In addition, complete the CMS 588 or EFT information and include a voided check or letter from your banking institution. There are specific elements to include on the letter from your bank if this option is chosen over sending a voided check.
As an individual provider working for a clinic enrolled with Medicare (whether as the owner or not), submit form 855R Reassignment of Benefits. This information directs Medicare to accept claims for services provided by the individual—but billed by the clinic—for processing and payment. Payment is made to the clinic or group on the provider’s behalf and the provider is compensated per the contract with that clinic.
To participate or not to participate
Both individual and group entities must decide whether to enroll as a participating or non-participating provider. This can be indicated on the CMS 460 form and it is a personal choice. If you choose to be non-participating and to reassign benefits to a group that is participating, the services being billed by that clinic will be processed at the clinic participation level, regardless of your participation level.
If you do not reassign your benefits, then you bill Medicare for those services and payment will be made to you or the patient (as indicated by the assignment). Also, benefits will never be reassigned to another individual provider, only to a clinic or group.
There are a few nuances between participating and non-participating. As a participating provider, charging your actual fees to Medicare on the claim form is allowed, but they will automatically reduce the fee to the allowed amount and then process the claim.
Acceptance of assignment is automatic on all claims and the payment from Medicare will be electronically transferred into your account on record with them. If a participating provider, your allowed amount is 5 percent higher than that of a non-participating provider.
Non-participating providers cannot charge their actual fees. Instead, they must adhere to the Medicare Fee Schedule published on each MAC website. As a non-participator, you can charge the non-participating allowed amount, of which Medicare will pay 80 percent on approved claims. Or, you may charge as high as the limiting charge, which is 115 percent of the allowed amount.
As with the allowed amount, non-participating providers will have a contractual write-off because Medicare only pays 80 percent of the allowed amount. As a non-participator, you are also able to choose on a claim-by-claim basis whether the payment is delivered to you or the patient.
If you accept assignment, collect only the co-insurance portion of the non-par allowable fee at the time of service. If you do not accept assignment, you can collect the full allowed amount and the 80 percent reimbursement from Medicare will go directly to the patient.
It is all about the D-E-T-A-I-L-S
When submitting information to Medicare, regardless of the format, remember they are sticklers for details. For example, if your name is John P. Smith III on your NPI number or license, it should read exactly the same on your Medicare enrollment. If your address on the application does not match the one on your voided check, it will be sent back for correction.
The devil is in the details. Medicare does allow, however, ample time and multiple attempts to acquire all necessary information. There are timelines in effect though; if asked to correct an application, whether online through the PECOS or by paper, do so in a timely manner or your application will be closed, and the process will have to be reinitiated.
Once the application is submitted, approval can take anywhere between 30 and 120 days for you to receive your PTAN. Once approved, notification will be sent two ways: an email confirmation and a letter through the mail. Keep both for your records.
Next, mark two key dates at this point: the effective date of enrollment and the date when revalidation with Medicare is required. Physicians and non-physicians should revalidate every five years. For durable medical equipment, prosthetics/orthotics, and supplies (DMPOS) authorization, revalidation should be done every three years. Missing your revalidation within the appropriate timeframe will deactivate your status with Medicare and require going through the enrollment process again.
Performing due diligence prior to submission as well as maintaining thorough and accurate documentation of your information will make this process seamless. If you desire the added security of experienced guidance, obtain professional assistance.
Kathy Mills Chang is a certified medical compliance specialist (MCS-P), a certified chiropractic professional coder (CCPC), and a Certified Clinical Chiropractic Assistant (CCCA). Since 1983, she has been helping chiropractors improve the performance of their practices. She leads a team of 30 at KMC University and is a foremost expert on Medicare, documentation and CA development.
Rhonda Hodge, MCS-P, has extensive experience with the regulations, training, and guidelines associated with the Occupational Safety and Health Administration (OSHA). She is also well-versed in safety and loss prevention and is currently focused on compliance.
Kathy or any of her team members can be reached at 855-832-6562 or info@KMCUniversity.com