The Centers for Medicare and Medicaid Services (CMS) has recently revamped the process by which Medicare providers and suppliers enroll in Medicare for the first time or complete a change of ownership. The changes streamline the process, provide clearer instructions and are intended to facilitate the role of the Medicare intermediaries and carriers in enforcing Medicare regulatory requirements.
CMS has issued the following five new application forms, which replace the HCFA 855 series of Medicare enrollment forms: CMS 855A for hospitals and other providers that submit bills to Medicare intermediaries; CMS 855B for physician group practices and other suppliers that bill Medicare carriers; CMS 855S for suppliers of durable medical equipment, prosthetics, orthotics and other supplies; CMS 855I for physicians and other individual practitioners; and CMS 855R for individual practitioners who reassign Medicare benefits to another supplier or provider. The five forms have the same organizational structure and section numbering, except for the CMS 855R, which is typically used in connection with a CMS 855B. Providers and suppliers were required to begin using the new forms on January 1, 2002.
Scope of Information Requested
The applications are generally less burdensome than the HCFA 855 series of forms in terms of the amount of information requested. For instance, while the applications still request identification of the owners of the applicant, they no longer require detailed information about the Medicare and Medicaid provider numbers of other providers and suppliers under common ownership or control of an organization, manager or director. Further, the applications no longer request information about every vendor of medical services or supplies with a value of $10,000 or greater in a 12-month period. Thus, an applicant-hospital that is part of system of other hospitals and providers need not assemble and disclose a list of the Medicare and Medicaid provider numbers of the other providers in the system or the hundreds of vendors with which it does business. These changes substantially reduce the amount of time required to complete the applications.
The new applications, however, request some information not previously required to facilitate the carriers’ and intermediaries’ role in verifying and enforcing compliance with various Medicare regulatory requirements. For instance, the billing agency section of forms 855A, 855B, 855S and 855I include questions related to compliance with the Medicare reassignment rules. The old HCFA 855 series of forms only required identification of the billing agency and a copy of the billing agreement.
In addition, section two of the applications, concerning the type of provider or supplier submitting the application, requests information necessary to determine compliance with various regulatory requirements. For instance, the 855B requests information necessary to determine whether a group of physical therapists or occupational therapists meets the requirements to participate in Medicare as physical therapists or occupational therapists in private practice. In addition, the 855A asks whether an applicant seeking to enroll as a federally qualified health center or organ procurement organization has the necessary approvals from the U.S. Department of Health and Human Services. Because the applications include these additional questions, the officer signing an application effectively certifies that the applicant is in compliance with the reassignment rules or other applicable regulatory requirements.
Adverse Legal Actions and Overpayments
The new forms also redesign and expand the section of the applications regarding adverse legal actions affecting the applicant. An applicant must disclose whether a wide range of adverse legal actions has been imposed against the applicant. If so, the applicant must provide specific documentation in connection with the adverse legal actions even if an appeal is pending or ultimate resolution of the matter was favorable to the applicant. The revised application also instructs providers to query the Health Care Integrity and Protection Databank to confirm whether the applicant has been subject to reportable adverse actions.
Section three of the application also requires the applicant to disclose whether it is subject to any outstanding Medicare overpayment determinations under any of its Medicare billing numbers. An applicant’s deliberate failure to disclose any overpayments could subject the signer of the application to criminal or civil sanctions. Further, by signing the certification statement, the official agrees to notify the applicable intermediary or carrier of any new information, such as an overpayment subsequent to the submission of the application, of which the official becomes aware. The revised instructions specifically provide, however, that overpayments occurring after the supplier’s enrollment has been approved need not be reported unless a provider seeks to enroll with a different Medicare carrier or intermediary. It is also important to recognize that the 855 forms do not require self-disclosure of potential overpayments of which a provider may be aware. The disclosure required by the 855 forms is limited to overpayment determinations made by CMS or its carriers and intermediaries.
Mobile Facilities and Portable Units
The practice location section of the applications has been revised to reflect that some suppliers participate in Medicare as mobile facilities or portable units. The section now requires the applicant to identify the base of operations and vehicle information if the mobile services are rendered in a vehicle. This improvement will facilitate the enrollment of mammography vans and other mobile facilities.
The applications have a new section requesting information about staffing companies. A staffing company is an organization that contracts with health care professionals (e.g., physicians) or a group of professionals to furnish health care at medical facilities (e.g., hospitals) where the organization is under contract with the facility to supply such staff. A facility that contracts with a staffing company to supply professionals must disclose the identity of the staffing company on the 855A form. Likewise, if a staffing company uses an individual professional or professional group to satisfy its obligations under a staffing contract, then the individual or group must identify the company on a CMS 855I or 855B that it files with a Medicare carrier. The purpose of these disclosures is apparently to enable Medicare to discover and prevent violations of the Medicare Reassignment Rules.
The Reassignment Rules generally prevent a staffing company from billing Medicare in its name for services or supplies furnished under a staffing arrangement. Instead, the Reassignment Rules usually permit the facility, the individual professionals provided by the staffing company or any group employing the professionals to bill for the services furnished under the staffing arrangement.
For instance, a hospital that contracts with a staffing company to supply emergency medicine physicians for its emergency department must disclose the identity of the staffing company on the 855A form. Under such staffing arrangement, the hospital, the emergency medicine physicians or a group employing the physicians may bill for the professional services furnished in the hospital’s emergency department.
IDTFs and Ambulance Companies
The new applications also revise the attachments for independent diagnostic testing facilities (IDTFs) and ambulance service providers to better evaluate compliance with the regulatory requirements applicable to these provider types. For instance, the revised attachment for IDTFs still requires identification of the equipment used to provide diagnostic testing services, a list of the diagnostic testing furnished by CPT or HCPCS code, identification of the interpreting physicians and the non-physician personnel who perform the diagnostic testing for the IDTF. The attachment now also requests identification of the physicians who provide the levels of physician supervision required for the performance of testing by non-physician personnel. For additional information about the level of physician supervision required for diagnostic testing, see our Health Law Update dated June 27, 2001.
Changes to Enrollment and Change of Ownership Process
CMS has changed the manner in which enrollment and change of ownership applications of hospitals and other providers, which bill intermediaries, are submitted and processed. These providers are no longer required to send their applications to the Medicare state agency for the provider’s state of residence for review and forwarding to the appropriate intermediary. The providers may now send applications directly to their intermediary of preference. However, as before the change, a provider may not be able to complete the enrollment or change of ownership process until the state in which it does business has issued all licenses and permits necessary for the operation of the provider. Accord-ingly, a provider should immediately notify its state agency of the proposed enrollment or change of ownership so the state agency can provide any additional license applications or other paperwork required in the state to the provider for the provider’s preparation and submission.