What Practitioners Need to Know About Medicare Provider Enrollment

As we get further into the new year, many practitioners are addressing aspects of their practice management that they feel could use expanded upon.

For many providers, this means making sure they’ve crossed all the t’s and dotted all the i’s when it comes to Medicare Provider Enrollment.

Since there are so many highly specific requirements for Medicare Enrollment, today we’ll be breaking it down to help you understand what steps you need to take to complete the task!

Getting Started

In order to be eligible for Medicare payment, there are forms that must be submitted that will enroll physicians to be available to receive the documentation necessary for eligibility.

Those forms are:

• Medicare Enrollment Application for Physicians and Non-Physician Practitioners (Form CMS-855I): This application is used for physicians/non-physician practitioners getting started with the enrollment process, or those who need to make changes to their initial application

• Medicare Enrollment Application for Clinics/Group Practices and Certain Other Suppliers (Form CMS-855B): This application is for group practices or organizational suppliers to initiate or update the enrollment process

• Medicare Enrollment Application for Reassignment of Medicare Benefits (Form CMS-855R): This application is for individual practitioners and non-physician practitioners looking to initiate a reassignment of a right to bill the Medicare program and receive Medicare payments

Initial Enrollment

In order to apply for enrollment or provide updates to their current application, providers have two options:

• The Internet-based Provider Enrollment, Chain and Ownership System (PECOS), or

• The paper enrollment application process (e.g., CMS-855).
  
  

For additional information regarding the Medicare enrollment process, including Internet-based PECOS, go to http://www.cms.hhs.gov/MedicareProviderSupEnroll

Reporting Changes

In order to report changes, providers must submit a new application to reinitiate the approval process. Providers must report changes in ownership or control, changes in practice location, or final adverse action within 30 days of the change.

Any other changes that need to be made must be reported within 90 days of the reported event.

What “Participation” Means

Participation in reference to Medicare Enrollment means continued agreement to always accept assignment of claims for services provided to Medicare beneficiaries.

Additionally, agreeing to accept assignment of claims means that you are also agreeing to always accept Medicare-allowed payments in full and to not collect more from the beneficiary.

Unlike with private insurance, through the Social Security Act, you are required to submit claims for Medicare whether you participate or not.

Benefits

If you do decide to participate in the Medicare program, you must also submit a participation agreement - the Medicare Participating Physician or Supplier Agreement (Form CMS-460). 

Typically, this form would be submitted concurrently with the enrollment form, but can be submitted within 90 days. Benefits will not begin until the form is submitted.

Benefits of Medicare enrollment include:

• Medicare reimbursement is 5 percent higher than it is for those who do not participate.

• Medicare payments are issued directly to the physician/supplier because the claims are always assigned.

• Claim information is forwarded to Medigap (Medicare supplemental coverage) insurers.

Additional Information

For more information on the Medicare Enrollment process, visit http://www.cms.hhs.gov/MedicareProviderSupEnroll to access the internet-based forms or to download the paper versions.