Medicare & Medicaid Provider Enrollment

Medicare & Medicaid

Provider Enrollment

Presented by Zabeen Chong, Director Provider Enrollment & Oversight Group Center for Medicare & Medicaid Services

Charles Schalm, Deputy Director Provider Enrollment & Oversight Group Center for Medicare & Medicaid Services

Session Overview

? How Enrollment Works ? Medicare Policy Updates ? Medicaid Enrollment ? Revalidation ? Our Enrollment Systems ? Protecting the Program ? Enforcement Actions

2

First thoughts

1

2

3

Listening to you

Finding a balance

We hear you, and we've learned a lot from you.

We believe enrollment should be easy for most providers, and hard for bad actors.

Always improving

We will keep refining our systems, policies, transparency, and our vision.

3

How enrollment works

4

How enrollment works

Submission

1

Intake

2

Processing, Screening & Verification

Submit to MAC

855Form 60 days*

? MAC mail room

? Manual data entry

3

PECOS

Medicare

Online

Providers &

45 days*

Suppliers (w/NPI)

Direct Input

4

Finalization & Claims Update

Update claim system MAC updates claim

system (1-2 days)

Provider not approved 6 until claims updated

MAC Recommendation to State /RO Certified providers/suppliers MAC recommends to RO RO performs in 3-9 mo

5

Development Letter

* If the app is complete, and no site visit

Pre Screening signed + dated app fee (or waiver) supporting docs all data elements

5

Verification

Name / LBN SSN / DOB NPPES Address License Adverse Actions

Risk Based Fingerprints Site Visits

What causes delays?

30-35%

delayed

need at least 1 round of corrections

missing documents

IRS documents, CMS 588 EFT, voided check, bank letter, education documentation, par agreement, cert term page, org charts

missing fields missing signature/date wrong signature (paper) incorrect information missing application fee

How the MAC develops for missing information

Contacts the...

1. Contact person (sec 13) 2. Individual provider (sec 2) 3. Auth or Del Official (sec 15/16)

By...

email fax phone letter

6

30

days to respond

No response?

delays rejections later effective date

MAC Notification Letters

Who is listed on MAC notification letters?

MAC analyst is the point of contact listed on the letter

MAC call center is the point of contact listed on the letter

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Medicare effective dates | Part B

Effective date is the later of: Application Receipt Date Date of first services at a new location (up

to 30 days prior to application receipt)

MAC

Option A: Early Submission Physicians / Groups can apply 60 days prior **

receives app APR 1

MAC approves MAY 15 (w/ effective June 1)

Provider seeking effective date JUNE 1

Provider performs service JUNE 1

MAC PROCESSING

MAR

APR

MAY

JUN

JUL

AUG

SEP

OCT

Option B: Late Submission Physicians / Groups effective date up to 30 days prior to submission date ***

Provider performs service JUNE 1

MAC PROCESSING

MAC receives app JULY 1

MAC approves SEPT 1 (w/ effective June 1)

** Must be in compliance at requested effective date (operational, licensed)

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