Over the past few months, the Centers for Medicare and Medicaid Services (CMS) and the Texas Medicare contractor, Trailblazer Health Enterprises have initiated widespread enrollment revocation proceedings against numerous Texas physicians and health care suppliers. Possibly in response to pressure to clean up Medicare enrollment records, CMS has begun to use a seldom enforced regulatory provision authorizing it to revoke the enrollment of a provider whose enrollment information is not current, particularly with respect to physical address. Revocation of enrollment is a minimum of one to three years.
Medicare regulations require all Medicare providers and suppliers to resubmit and recertify the accuracy of their enrollment information every five years. In addition, when that information changes, suppliers (including physicians) must report the enrollment changes to Trailblazer within 30 days for a change of ownership, any adverse legal action, or a change in practice location, and within 90 days for changes to all other enrollment information.
The biggest danger occurs when a physician group closes an office, or opens a new office to replace the old office. In either event, the physician must notify the Medicare carrier within 30 days by filing a Form 855B Change of Information. Under the regulations, CMS may make site visits to a Medicare provider or supplier’s location to determine if the entity is still furnishing Medicare covered items and services at that address. Through various audit tools, CMS has identified suppliers in Texas that it believes have not notified CMS of address changes. CMS then schedules a site visit to a closed office, determines that the supplier is in fact no longer furnishing Medicare items or services at that location, and then exercises discretionary authority under the regulations to revoke the enrollment for that supplier. This has the same effect as a debarment on the basis of formal sanctions under other Medicare rules that have usually been applied on the basis of intentional conduct.
Understandably, CMS may want to revoke the Medicare privileges for a supplier that is no longer operating. However, revoking the enrollment of a large medical group with multiple locations, simply because one location was closed without timely notifying the carrier, is a draconian remedy that can force suppliers out of business and leave hundreds or thousands of Medicare beneficiaries without a treating physician. Efforts to overturn these revocations have had mixed success. In most circumstances, the economic and patient continuity damage done by an enrollment deactivation or revocation is impossible to correct.
What is the best way to prevent this from happening to your practice? Staff should be intimately familiar with the CMS Form 855B and the Provider Enrollment, Chain, and Ownership System (PECOS). Any time your Medicare enrollment information changes, whether it is adding or deleting owners, adding or deleting offices, or changing address information, such changes must be filed with the carrier within 30 days of the date of the action. If the Medicare contractor requests filing of a revalidation enrollment form, do not ignore that request. Suppliers who fail to provide revalidation information within 60 days of request are also subject to enrollment revocation.
The recent 21% cut in Medicare reimbursement to physicians has resulted in the voluntary defection of many physicians from the Medicare program, so it remains to be seen whether the involuntary removals of physicians from the Medicare program can be sustained, as fewer providers remain for an increasing number of Medicare patients. </p>