Medicare Credentialing

Medicare credentialing is a complex process and is a very difficult task for most practices, doing it for the first time. It is very important that practices know the intricacies of Medicare credentialing, if they plan to do the credentialing themselves. For most practices, the majority of their reimbursements are from Medicare, also most insurances follow the same processes as Medicare. A proper understanding of Medicare's credentialing process is crucial to the success of every practice.

For most physician practices, Medicare requires three (3) basic applications which make up the 855 series,

1. 855I – Create or reactivate a physician’s individual number

This Medicare form is used to obtain a physician’s individual Medicare number from each state’s supplier. The physician must submit a copy of the medical school diploma and NPI letter with the individual NPI number with this form. Medicare requires an 855I application if any changes are made to the physician’s file. Also, Medicare will deactivate a Medicare number and require an 855I reactivation if a significant lapse occurs in billing or if no claims are submitted to the number issued.

2. 855B – Create or change a practice's group number

This Medicare application is used to obtain a group number for billing purposes. The physician must submit a copy of the IRS letter with this form. Groups already participating with Medicare use the form to make changes to physician listings, such as practice ownership, phone number, address, NPI group numbers, etc. You will be required to complete an 855B form if you make any changes to your practice, such as add a new physician for billing, change address, change billing, etc.

Ensure that the practice name, bank account details, contact person details are filled in accurately. Errors will delay the acceptance of your application.

3. 855R – Links the physician’s individual number to the group number

This Medicare form is used to reassign the benefits of the physician to the group. The group’s authorized official signs the form in addition to the individual being linked to the group. When reassigning the benefits of a physician to a group you may submit the 855R and 855I together if the provider's Medicare number needs to be reactivated e.t.c.

If the Medicare application is incomplete or incorrect, the Medicare process can take more time and in some cases the process can take about six months for approval.

Some points to note in the Medicare credentialing process,

• When reactivating physician billing privileges, the effective date will now be the later of either the date of filing the Medicare enrollment application (date stamped by Medicare), or the date the physician first began providing services at the new practice location
• When submitting the Medicare forms to a Medicare intermediary, ensure that the practice name is exactly as it appears on the Bank account, the IRS letter and the NPI letter

The Medicare credentialing process though complex can be managed by ensuring that the credentialing information on the 855 forms is accurate and consistent, so that Medicare is able to process the credentialing application without delay.

Getting a DME License

Durable medical equipment (DME) is provided by home healthcare agencies, physicians or DME companies. DME is generally defined as medical equipment that is not disposable, is medically necessary and appropriate for home use.
The process for getting a DME license is as outlined below,

1. Apply for an Employer Identification Number (EIN). This number serves as your business identity for tax purposes.
2. Contact your state's department of health and obtain information regarding the state licensing application process and application. State laws vary greatly, from one state to the other, so what is required in one state may not be required in another.
3. Apply for a National Provider Identifier (NPI) from Centers for Medicare and Medicaid Services (CMS). This unique Physician identifier is a standard set by CMS and is required for reimbursement for products and services provided to patients.
4. Review the 26 Supplier Standards from the Medicare Enrollment Application and complete the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Medicare Enrollment Application. Once you are accepted as a DMEPOS supplier, you can bill Medicare for equipment provided to Medicare recipients.
5. Contact a DME accreditation program. An accreditation from a CMS-approved compliance program is needed in order to be accepted to the DMEPOS program. These compliance companies ensure that DME suppliers are following the 26 Supplier Standards. 
6. Submit the state application and prepare for inspection, if applicable. You may pay any applicable application and inspection fees alongwith your application.
7. Prepare for compliance inspection. The compliance company will send you items that they will inspect, but the list is not all-inclusive. Upon completion of the compliance inspection, you will receive the results and become accredited.
8. Submit DMEPOS application with all of the required documentation. Once your application is approved, you will receive your Medicare supplier number.
   

No coverage / Coverage terminated

Many times we come across the denial "Denied for No coverage or Coverage terminated", whenever we come across this denial we usually assume that the patient does not have coverage. This is not always true, let us review the following scenarios.

Scenario 1
The payor issued a new ID to the patient, while the claim was submitted with the old ID, hence the denial. So we need to call the payor or go online and search the patient. This way we can pull the patient's correct ID, update that in our records and have the claim resubmitted.

Scenario 2
The denial could be in error in which case we can verify this by calling the payor or checking online. We will also know by checking the claim history, if the payor has been paying claims before and after the date of service being denied by them, then it is obvious that this claim has been denied in error. A call to the payor will resolve this claim.

Scenario 3
The denial could be correct we can verify this by calling the payor. We need to call or check online and see whether we are able to pull up this patient, if we cannot find any information about the patient then we need to contact the patient. We can send a patient statement stating that the charges are being billed to the patient as the insurance has denied citing no coverage. If the patient has a new insurance, he would update us on receiving the statement. With the new insurance information the claim can be resubmitted.