Some healthcare providers probably missed an important change buried within the 2009 Medicare Physician Fee Schedule: New rules for physician enrollment have drastically reduced the period for retroactive billing. Effective April 1, physicians enrolling or re-enrolling with Medicare can only submit a bill for services provided up to 30 days prior to the effective date, rather than for the prior 27 months.
Those who miss this deadline will be denied reimbursement for services to Medicare patients seen before the deadline. And those who move to a new job (“change of location,” in Medicare parlance) and fail to update their address within 30 days risk a two-year suspension from receiving Medicare payments.
What It Means
Essentially, HM group leaders must make sure they are ready to credential a new hire long before they start working. Before now, groups had months to get new hires enrolled in the Medicare system; now, with just 30 days to enroll, you need to start your credentialing and enrollment process early—before the physician’s start date, if possible.
“In a nutshell, groups are going to have to be more proactive than ever before in getting paperwork submitted for new providers,” says Derise Woods, operations project manager for Knoxville, Tenn.-based TeamHealth. “The situation we often face is that the provider is found and placed, and sometimes the paperwork does not get submitted right away. The natural focus is to get them on board and then get them up and running.”
If that is the case in your group, you should create a checklist for enrollment in Medicare and for other payors. Then, as soon as your new hire signs the contract, require them to submit all available information (e.g., DEA number and proof of board certification).
Woods says the rule states that “retroactive billing can start from the provider’s start date or from the date the enrollment is received at [Medicare], whichever is later.”
Even if you don’t capture all the necessary information, enroll the new physician as soon as possible. According to the Centers for Medicare & Medicaid Services (CMS), incomplete applications will be denied, but the date of the original filing will be preserved. So if a hospitalist begins working for your group Sept. 1, and you submit the enrollment application Sept. 7, the hospitalist can bill retroactively starting Sept. 7, even if that application is kicked back to you for more information and doesn’t get resolved for several weeks.
—Derise Woods, TeamHealth, Knoxville, Tenn.
Large and Small Groups
Missing the new enrollment deadline means reimbursement losses. Hospitalists provide services to a significant number of Medicare patients, so cutting back on retroactive billing could hurt the bottom line. “In most [HM] instances where Medicare is a large portion of income, this has potential to disrupt a practice,” Woods says, noting TeamHealth has yet to see the impact of the new enrollment rules.
Which entity incurs the loss of Medicare payments depends on your program’s payment structure. “For instance, TeamHealth contracts with our providers and pays them an hourly rate,” says Woods, explaining that the third-party contractor will suffer any loss of fees. “In a hospital-based program, the hospital might bill for the provider—and that provider may not get paid.”
Smaller HM groups might not have as much experience with these changes simply because they don’t hire physicians as often. “I did not know about this,” says Heidi Tessler, MD, president of the Colorado Hospitalist Company in Denver. “We contract with a billing company [for physician enrollments], and we would have been caught flat-footed with our next hire.”
Small groups could end up scrambling when they need to fill a position, especially if it’s a quick turnover. Groups that outsource their recruiting and billing should plan to communicate with those companies to expedite the enrollment process, Woods says.
TeamHealth, the largest provider of hospital-based clinical outsourcing in the U.S., has made numerous changes to accommodate the new enrollment rules, all the way up to a new business development group. “They now take this new rule into consideration when we are planning to start providing service,” Woods says. “Our recruiters are helping. They are ensuring that new providers fill out their paperwork and get it in. Understandably, physicians can let paperwork sit for a number of days.”
The good news is CMS has made it easier—and faster—to enroll through a Web-based portal called PECOS (Provider Enrollment, Chain, and Ownership System), which can be accessed at www.cms.hhs.gov/MedicareProviderSupEnroll/.
SHM has consolidated essential sources on the new rules to include:
- Medicare’s all-inclusive Web section on provider enrollment is www.cms.hhs.gov/medicareprovidersupenroll.
- The CMS manual on enrollment is at www.cms.hhs.gov. Click on “manuals,” then “Internet-only manuals”; select “Publication 100-08, Program Integrity Manual,” then “Chapter 10.”
- AMA provides an overview on its Web site, and, with the Medical Group Management Association (MGMA), has developed a toolkit to guide physicians through the new rules. “The toolkit is probably the best resource available,” says Leslie Flores, principal in Nelson/Flores Associates, a national hospitalist management consulting firm and director of SHM’s Practice Management Institute. AMA and MGMA members can access the toolkit at www.mgma.com/policy/default.aspx?id=5712.
“SHM wants to make sure we communicate these new rules to our members,” says Flores, “and provide direction to resources they can use.” Check www.hospitalmedicine.org for the latest links and information. TH
Jane Jerrard is a freelance writer based in Chicago.