New Medicare Rule Reduces Retroactive Billing Period


Medicare enrollment rules for retroactive billing implemented this month may catch some hospital medicine leaders by surprise—and cost them billing revenue.

The new rules from the Centers for Medicare and Medicaid Services (CMS), effective April 1, cut from 27 months to 30 days the window in which physicians can back-bill for services after successful enrollment or re-enrollment in Medicare. Most HM groups routinely allow new hospitalists to work prior to payor credentialing, then retroactively bill for those services once credentialing is completed, says Leslie Flores, MHA, a principal in Nelson/Flores Associates, an HM consulting firm in La Quinta, Calif., and director of SHM's Practice Management Institute.

Another provision of the rules states that practices must alert contractors of any changes in practice locations within 30 days, or risk expulsion from Medicare for as much as two years.

“This is likely to impact hospital medicine more than other specialties because of our rapid growth, the proportion of new graduates we hire, and the frequency with which hospitalists move around,” Flores says.

Marshall Maglothin, chief operating officer of Inpatient Specialists, which staffs 70 hospitalists at three Washington, D.C.-area hospitalists, suggests HM leaders read the new Medicare Provider Enrollment Toolkit, recently issued by the American Medical Association (AMA) and the Medical Group Management Association (MGMA). The resource includes an introduction to CMS’ Web-based version of the Provider Enrollment, Chain and Ownership System (PECOS), which became available this month for both HM groups and individual hospitalists. To download the toolkit, visit

“Until this gets worked over the next couple of months, there’s going to be a lot of missed revenue,” says Maglothin, who also runs HM advisory firm Blue Oak Consulting. “This is the ideal timeline, but it’s totally unrealistic when you’re dealing with over 600,000 physicians in the United States. There should have been an ease-in process.”

To help smooth the transition, CMS will hold a conference call to discuss provider issues at 2 p.m. (EST) Thursday. Capacity is limited, but to participate, call (800) 837-1935 and reference conference No. 94109369.

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