Achieving recognition as an eligible provider for Medicare used to be a fairly intensive and laborious process. And because the process of attaining billing privileges depended on the proverbially slow snail mail system, the length of time it took to become eligible seemed even longer. However, with the welcome establishment of the Internet-based Provider Enrollment, Chain and Ownership System (PECOS), providers have the option of enrolling, making a change to their information, or tracking the status of their application using a far more efficient Internet submission process.

There are other notable processes in the Medicare provider enrollment system of which you should be aware as well. According to the March 13 CMS transmittal R286PI there are specific parameters for which providers can bill based upon the effective date of their billing privileges. Contractors may have been doing this differently, but over time the process should become more consistent with the requirements specified in chapter 10 of the Program Integrity Manual.

Retroactive billing

When a physician or nonphysician practitioner (NPP) becomes associated with a group practice, the practice must do the paperwork so Medicare will recognize the practitioner as a member of the group. While the paperwork is being processed, the practitioner is permitted to see patients assuming he or she is in compliance with state licensure. After the paperwork with Medicare is completed, the practice may then retroactively bill for services the practitioner rendered.

Effective April 1, Medicare is limiting retroactive billing to the later of the actual date of the filing or from the date the practitioner first began furnishing services. However, practitioners can retroactively bill 30 days prior to their effective date of billing privileges "if circumstances precluded enrollment in advance of providing services to Medicare beneficiaries," according to the transmittal.

CMS offers no further elaboration on qualifying circumstances. It seems though, that CMS is willing to be flexible with the 30-day time period of retroactive billing prior to the effective date of billing privileges. (Note: "filing the paperwork" means the date the contractor received the complete enrollment application and a signed certification statement.)

For example, your practice has a physician who starts working on the first of the month. Two weeks later, you file a complete CMS 855I with the signed certification statement. The effective date of billing privileges is technically the date you filed the 855, but you will be able to retroactively bill for all services rendered because you did not exceed 30 days prior to the effective date. Had your physician been seeing patients for five weeks prior to filing the paperwork with Medicare, then the first week would have been charity care as far as Medicare was concerned.

Deactivated billing privileges

CMS provided another interesting example of retroactive billing in the transmittal:

Dr. Joe's Medicare billing privileges were deactivated due to 12 consecutive months of non-billing on October 1, 2009. Dr. Joe submits an enrollment application on December 15, 2009 to reactivate his billing privileges. In this case, Dr. Joe's enrollment application indicates that he started seeing patients at this location on January 1, 1998. Dr. Joe's effective date of filing is December 15, 2009, while his effective date of billing is November 16, 2009. Dr. Joe is precluded from receiving payment for services rendered between October 1, 2009 and November 15, 2009.

The messagedon't let your billing privileges be deactivated! In this example, Dr. Joe lost his ability to bill for services rendered to Medicare patients for six full weeks. Deactivation means that billing privileges stopped, though Medicare could restore them upon the submission of another CMS 855 form. Contractors may deactivate a provider's Medicare billing privileges when the provider submits no Medicare claims for 12 consecutive calendar months. The 12-month period begins on the first day of the first month without a claims submission through the last day of the 12th month without a submitted claim.

Medicare deactivates providers' billing privileges after a year because significant lengths of inactivity cause a problem for the government. Contractors are unable to ensure that the data provided by the applicant at the time of enrollment is still current. This inability to ensure correct provider data creates vulnerabilities for fraudulent and inappropriate use of an inactive billing number.

To resume status as an active Medicare provider, the inactive practitioner must completely resubmit their enrollment forms, which is no small feat. The CMS 855I is a 29-page form that the government estimates takes approximately four hours to complete. You don't want to have to do that more than once!

Keep in mind that providers are obligated to inform contractors of changes to pertinent information regarding their practice. When the change involves a change of ownership, a final adverse action taken against the provider, or a change in practice location, CMS says you have 30 days to let them know. You have 90 days to inform CMS about other types of changes.

The revalidation cycle

One final note: CMS has adopted a five-year revalidation cycle-meaning that CMS validates that all information pertaining to a provider is still current every five years. Don't complain! CMS originally proposed a three-year revalidation cycle, but CMS agreed to a five-year cycle based on feedback given during the comment period. CMS acknowledged that a five-year cycle would significantly decrease the burden on providers.

Contractors initiate the revalidation process, so when your number is up, respond in a timely manner-within 30 days of the date the contractor sent the request for additional information.

The contractor may deny the provider's application when the provider fails to furnish complete information on the enrollment application, including all supporting documentation. When the provider furnishes only part of the requested data within the applicable time period, the contractor is not required to contact the provider again to request the remainder of the information. The contractor has the discretion to extend the 30-day time period if it determines the provider or supplier is actively working with the contractor to resolve any outstanding issues.

Peggy S. Blue, MPH, CPC, is a regulatory specialist for HCPro, Inc. Blue is an instructor for the Certified Coder Boot Camp® - Original Version and Certified Coder Boot Camp® - Inpatient Version, which covers physician and outpatient hospital coding. For more information, visit www.hcprobootcamps.com.