Medicare enrollment now required for part D prescribing

Medicare Provider Enrollment Changes

Last last week, the Centers for Medicare & Medicaid Services (CMS) issued a final rule for Medicare Advantage and Medicare Part D that includes provisions directly affecting physicians. Beginning June 1, 2015, in order to prescribe under Medicare Part D, physicians or eligible prescribers must be enrolled in Medicare or, for those who have opted out of the program, have a valid affidavit on file with their Medicare contactor. Medicare Part D sponsors must deny pharmacy claims for providers who do not meet this criteria. See the entire final rule here.

CMS also finalized a proposal allowing the agency to revoke the Medicare enrollment of a physician or eligible professional who has a practice of prescribing Part D drugs that is abusive, fails to meet Medicare requirements or represents a threat to the health and safety of Medicare beneficiaries. CMS states it only plans to exercise this new authority in very limited and exceptional circumstances. Action related to this new provision may begin as early as July 22, the effective date of the rule.

Medicare Background Checks

Implementation of fingerprint-based background checks for Medicare Provider Enrollment

As part of the enhanced provider enrollment screening provisions of the Affordable Care Act (ACA) the Center for Medicare and Medicaid Services (CMS) is implementing fingerprint-based background checks for providers and suppliers in the “high” level risk category.  Initially, the new screening provisions will apply to newly enrolling DMEPOS suppliers, Home Health Agencies, and other providers and suppliers who have been specifically designated as high risk.

The fingerprint-based background checks will apply to all individuals with a 5% or greater ownership in an enrolling provider/supplier.  Once fully implemented, all individuals with 5 percent or more ownership in a high risk category supplier will be required to undergo fingerprint based background checks.

Fingerprints are preferred in electronic format from a finger-print based background check contractor (FBBC), but paper cards can be accepted on the standard federal form.  Providers will incur the cost of fingerprinting.

CMS will notify providers of the requirement and the provider will have 30 days from receipt of the notification to submit the information.  The notification letters will identify FBBC’s in the jurisdiction of the provider.  The provider will be responsible for the cost of fingerprinting.

For more detailed information, read the latest Medicare Learning Network article here. Details of the provision can also be found on the electronic code of federal regulations.

Medicare Revalidation Update

On November 4, 2013, CMS issued a notice of revision to reflect the current revalidation process.  Revalidation applies to all providers and suppliers who enrolled with Medicare prior to March 25, 2011.  Affected providers and suppliers must revalidate their information on file with CMS by March 2015.

CMS has announced that between now and 2015, local Medicare carriers (referred to as MAC’s) “will send out revalidation notices on an intermittent, but regular basis to begin the revalidation process for each provider and supplier.”  Furthermore, “Providers and suppliers must submit the revalidation application only after being asked by their MAC to do so”.

Where will letters be mailed?

For providers NOT in PECOS – the revalidation letter will be sent to the special payments or primary practice address because CMS does not have a correspondence address.

For providers in PECOS – the revalidation letter will be sent to the special payments and correspondence addresses simultaneously. If these are the same, it will also be mailed to the primary practice address. If you believe you are not in PECOS and have not yet received a revalidation letter, contact your MAC. Contact information may be found at on the CMS website.

CMS will provide the MACs with a list of providers/suppliers requiring revalidation every 60 days beginning October 2013. Within 60 days of receiving the CMS list, MACs will mail the revalidation notices.

Providers and suppliers have 60 days from the date of the revalidation letter to submit the complete enrollment package (including fee payment when necessary).  A 60 day extension is available if more time is needed to complete the revalidation process.  Extension requests must be submitted to your MAC in writing (fax/email permissible) or via phone.

The burden is on the Provider or supplier to submit revalidation applications within 60 days of the date of the issued revalidation letter.  MAC’s do not have any further responsibility of notification prior to terminating a provider’s billing privileges.  So, it is important that every Provider and Supplier alert staff to be on the lookout for a revalidation notice from CMS if you have not yet revalidated your information.  You can proactively search information on the CMS website to determine if a revalidation letter has been mailed.