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.

A B N Revised by CMS

CMS is notifying health care providers and suppliers that it has updated its Advance Beneficiary Notice of Noncoverage, or ABN form and made the revised form and information on how to use it available online.

Use of the revised ABN, which is issued to patients by physicians and other health care professionals, "in situations where Medicare payment is expected to be denied," will become mandatory on November 1, 2011. At that time, the old ABN form will be considered invalid, by CMS. 

Using the appropriate ABN form is critical to physicians getting paid, physicians would be well advised to start using the revised form before the deadline.

Physicians need to check the lower left hand corner of the document for the words "Form CMS-R-131" and the revised date "03/11" to ensure that they have the revised form in hand.

Practices must have a current and properly executed ABN, because if Medicare denies the services, the physician can't go back and collect payment from the patient. 

http://www.cms.gov/BNI/02_ABN.asp

Foot Care Coverage Guidelines

Covered foot care services

According to the Medicare Benefit Policy Manual (MBPM), Chapter 15, Section 290, Medicare-covered foot care services only include medically necessary and reasonable foot care.

Exclusions from coverage 

Certain foot care related services are not generally covered by Medicare. Whether performed by a podiatrist, osteopath, or doctor of medicine and regardless of the difficulty or complexity of the procedure, the following services are not covered by Medicare:

• Treatment of flat foot
• Routine foot care
• Supportive devices for feet

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.
   

PQRI 2011

The Physician Quality Reporting Initiative (PQRI) is a program to improve the quality of reporting in the healthcare industry. The program is now considered to be permanent and therefore the program name has been amended to the Physician Quality Reporting System (PQRS). PQRS reporting is based on individual measures which are associated to a specific patient group by diagnosis, ailment, age, or clinical action taken by the reporting therapist. All Medicare Part B FFS (fee for service) patients are eligible, but must meet inclusion criteria for each measure. 

There are three methods of reporting your clinical data to CMS:  Claims, Registry and EHR-based.  Choosing your reporting method is very important in reaching your 1% incentive goal.  

Claims-based Reporting
With claims-based reporting, measures are tied to clinical practice reported on claims with CPT codes that link to measures.


To qualify for your 1% incentive, you must report on at least 3 measures ( atleast 3 individual measures or atleast 1 measure group ) and report on 50% of eligible patients (this is a reduction from the 80% requirement of 2010).

Advantages of claims-based reporting:

1. You are in control of your own data from completion to submission
2. Cost effective – no added cost
3. Only 50% reporting requirement
4. OK for smaller practice or if Medicare is a small portion of your payer mix

Disadvantages of claims-based reporting:

1. Must have someone in the clinic who will own this project: complete audits, know all the ins/outs of PQRS, keep record of the % completed
2. Auditing process can be tedious and potentially a productivity loss for an employee
3. We must complete and submit the proper forms in proper format for the eligible patients
4. Workload could be significant if large % of your patients are Medicare or part of a large clinic

Registry-based Reporting
With registry-based reporting, the eligible professional or group practice submits the data electronically to the registry, who then captures and stores the measure related data. The registry is then responsible for submitting the individual measure or measures group information to CMS on behalf of eligible professionals.  Registries provide CMS with calculated reporting and performance rates at the end of the reporting period.  Registries must pass stringent reporting method criteria annually and be qualified to participate.
 
To qualify for your 1% incentive, you must report on at least 3 measures ( atleast 3 individual measures or atleast 1 measure group ) and report on 80% of eligible patients or report.
 
Advantages of registry-based reporting:

1. Form creation and submission is done by registry
2. No need for auditing due to the EMR enforcing measure criteria and selecting eligible patients
3. Staff productivity maintained
4. Higher potential for meeting the reporting criteria and receiving your 1% incentive bonus
5. Using a EMR registry gives you added insight and assistance with choosing most appropriate measures
6. Measures are updated automatically each year as information is provided by CMS

Disadvantages of registry-based reporting: 

1. There is a cost involved; but it is nominal ( around 300 $ per provider ) and definitely provides an ROI when staff time, paper/office supplies, and decreased stress levels are calculated
2. 80% reporting requirement, but with the EMR in place, 100% data collection should be the expectation
3. Data collection enforcement with all eligible patients – no choice but to report on each patient

The 1% incentive may not seem like much, if you have to spend staff time and effort to get the proper codes into billing, complete audits to ensure your clinic is meeting its minimum criteria, and manually submitting claims to CMS. Although there is a cost associated with using a registry, the savings on staff time and maintaining productivity alone is substantial.

EHR-based Reporting
Eligible professionals who choose to report on EHR measures need to select at least three EHR measures to report on to be able to qualify to earn a PQRI incentive payment.To qualify for the incentive, the correct quality action or performance exclusion will need to be reported on at least 80 percent of the eligible cases identified for each selected measure.


A case is eligible for PQRI purposes when the codes match the denominator inclusion criteria and are listed as PFS covered services according to the PQRI EHR Measure Specifications. Each measure has a reporting frequency or timeframe requirement for each eligible patient seen during the reporting period for each individual eligible professional.

Ensure all patient-care and visit-related information are documented in your EHR system. Ensure you identify and capture all eligible cases per the measure denominator for each measure you choose to report. Review all the denominator codes that can affect EHR-based reporting to make sure the correct quality action is performed and reported for the eligible case.

Create the required reporting file, which would be uploaded from your EHR system. A PQRI-qualified EHR would have been programmed already to generate this file. Submit final EHR reporting files with quality measure data by the data submission deadline.
 

Advantages of EHR-based reporting:

1. Cost effective – no added cost
2. EHR enforces measure criteria and selects eligible patients
3. Staff productivity maintained
4. Measures are updated automatically each year by EHR as information is provided by CMS

Disadvantages of EHR-based reporting:

1. Must have adequate training on the EHR to manage the PQRI process
2. Must generate and submit the EHR-PQRI reporting files
3. 80% reporting requirement, but with the EMR in place, 100% data collection should be the expectation