American Osteopathic Association

Advancing the distinctive philosophy and practice of osteopathic medicine

Medicare Enrollment Guide

New Medicare Enrollment Requirements Effective Feb. 3, 2015

The Centers for Medicare and Medicaid Services (CMS) has expanded its authority to deny or revoke Medicare provider enrollment privileges. Under the Dec. 5, 2014 final rule, which goes into effect Feb. 3, 2015, providers and suppliers (i.e., physicians) who have Medicare debts can be denied enrollment. Medicare debts encompass overpayments and other Medicare obligations. Currently, an enrollment application can only be denied when there is a Medicare overpayment.

In addition, CMS will have the ability to deny enrollment of physicians, as well as other providers and suppliers, affiliated with an organization that has an unpaid debt. According to CMS, this will help prevent individuals and entities from being able to incur substantial debt to Medicare, leave the Medicare program, and then re-enroll as a new business to avoid repayment of the outstanding Medicare debt. CMS will only enroll otherwise eligible individuals or entities if they repay the debt or enter into a repayment plan.

The CMS said some unpaid Medicare debts present no risk of fraud, waste or abuse to the Medicare program, therefore the agency will evaluate each situation on a case-by-case basis. If the unpaid Medicare debt poses no risk, then enrollment will not be denied. Other enrollment provisions in the final rule are as follows:

  • Adding the ability to deny the enrollment or revoke the billing privileges of a provider or supplier if a managing employee has been convicted of certain felony offenses. This provision ensures that CMS can block or remove bad actors from the Medicare program to protect beneficiaries and safeguard the Medicare Trust Funds, according to the agency.

  • Permitting CMS to revoke billing privileges of providers and suppliers that have a pattern or practice of billing for services that do not meet Medicare requirements. This is intended to address providers and suppliers that regularly submit improper claims in such a way that it poses a risk to the Medicare program.

Apply for Enrollment

Physicians and non-physician practitioners can apply for enrollment in the Medicare program or make a change in their enrollment information using either of the paper-enrollment application process (CMS-855I or CMS-855R) or the Internet-based Provider Enrollment, Chain and Ownership System (PECOS). The agency hopes that PECOS will help streamline the process and alleviate burdens related to the paper-based process.

Several changes to the enrollment process are in effect. For example:

  • A physician must submit a signed certification statement and supporting documentation with seven days of the electronic submission.

  • For applications submitted through PECOS, Medicare contractors must process 90 percent of the applications within 45 days of receiving the signed and dated certification statement and supporting documentation.

  • CMS requires Medicare contractors to process 80% of initial paper enrollment applications within 60 days, and 80% of paper changes and reassignments within 45 days.

  • A physician can file an enrollment application up to 30 days before providing services at the designated location.

  • A physician has up to 90 days to notify the Medicare contractor of all other changes in enrollment information other than the information subject to the 30-day notification window.

  • If errors are found on the application, physicians have 30 days to request a corrective action from the Medicare contractor in order to preserve the initial filing date and original retroactive billing window. CMS reserves the right to perform an onsite review of a provider or supplier to verify that the enrollment information submitted to CMS or its agents is accurate and to determine compliance with Medicare enrollment requirements.

  • Based on the results of the review, CMS may deny or revoke a physician’s Medicare billing privileges if he/she is unable to furnish Medicare-covered services; has failed to satisfy any of the Medicare enrollment requirements; or failed to furnish Medicare covered items or services as required by the statute or regulation.

  • CMS also can revoke enrollment and billing privileges in the Medicare program if the physician did not comply with reporting and documentation requirements in the enrollment process. The physician must submit all claims for items and services furnished within 60 calendar days of the effective date of revocation. (These requirements apply to other providers and suppliers as well.)