New Provider Enrollment Provisions
April 20, 2011 -  As designated under the Affordable Care Act, new provider enrollment provisions, designed to continue CMS’ efforts to reduce fraud, waste, and abuse, were published in the final rule with comment entitled, “Medicare, Medicaid and the Children’s Health Insurance Programs; Additional Screening Requirements, Application Fees, Temporary Enrollment Moratoria, Payment Suspensions and Compliance Plans for Providers and Suppliers” (CMS-6028-FC)
This rule, effective March 25, 2011, will affect all our clients but will have the most impact on our institutional providers: ambulatory surgical centers (ASCs), independent diagnostic testing facilities, independent clinical laboratories, mammography centers, portable x-ray suppliers and radiation therapy centers.
This rule finalized provisions related to the:
- Establishment of provider enrollment screening categories
- Submission of application fees as part of the provider enrollment process;
- Suspensions of payment based on credible allegations of fraud; and
- Authority to impose a temporary moratorium on the enrollment of new Medicare providers and suppliers of particular type (or the establishment of new practice locations of a particular type) in a geographic area.
Provider Screening
CMS will institute screening measures for providers and suppliers during their new or revalidation enrollment periods. The screening will be based on the provider or supplier’s level of risk posed to the Medicare system, categorized as limited, moderate or high.
Limited category – The screening procedures will largely be the same procedures that have been in place for some time and are currently in use.Â
Our clients in this category are:
physicians, non-physician practitioners other than physical therapists, medical groups or clinics, ambulatory surgical centers (ASCs), Mammography screening centers, mass immunization roster billers, and radiation therapy centers.
Moderate category – The screening procedures will include the current screening measures, as well as a site visit. Our clients in this category are: independent clinical laboratories, independent diagnostic testing facilities (IDTFs), physical therapists enrolling as individuals or as group practices, and portable x-ray suppliers (PXRS).
High category – The screening procedures will be the current screening measures, a site visit, and a fingerprint-based criminal background check. (at a future date)  Providers in this category include newly-enrolling DMEPOS suppliers and Home Health Agencies and any providers and suppliers reassigned from the limited or moderate categories due to triggering events. Triggering events can be payment suspension within the previous 10 years, billing privileges suspended by Medicare and/or Medicaid within the previous 10 years and several other events that have excluded providers and suppliers from Federal government programs due to some type of previous fraud and abuse.
New Enrollment Application Fees
Another provision of this final rule with comment is to impose a fee on each “institutional provider of medical or other items or services and suppliers.”  The fee is to be used by CMS to cover the cost of program integrity efforts including the cost of screenings associated with provider enrollment processes.
CMS has defined “institutional provider” to mean any provider or supplier that submits a paper Medicare enrollment application using CMS-855A, CMS-855B (except physician and non-physician practitioner organizations), or CMS855S forms or associated Internet-based PECOS enrollment application.
The application fee will be $505.00 through December 31, 2011and will be adjusted in future years based on the percentage change in the Consumer Priced Index – All Urban Consumers (CPI-U) and will apply to institutional providers that are:
- initially enrolling in Medicare
- adding a new practice location
- revalidating their enrollment information
Our clients who may have to pay an application fee when changing or updating their Medicare enrollment status are ambulatory surgical centers, independent diagnostic testing facilities, mammography centers, portable x-ray suppliers,radiation therapy centers and independent clinical laboratories.
The application enrollment fee does not apply to physicians or non-physician practitioners, whether the enrollment updates are for individuals or group practices.
A provider or supplier requesting a hardship exception from the application fee must include a letter and supporting documentation that describes the hardship and justifies the need for an exemption. This letter must accompany the enrollment application.
Payment of the application fee will be made through Pay.gov
More explicit information relating to provider screening, application fees and payment, hardship exceptions and moratoriums on enrollment can be found by clicking below for PDFÂ R371PI
Provider Enrollment Provisions
Tags: Provider Enrollment
