JO - Health Care Compliance Association

New Medicare enrollment regulations ...continued from page 25
forms. Within 30 days of any change in ownership
or control for any provider or supplier, or
any reportable change for a DMEPOS supplier,
updated enrollment forms must be submitted.
For all other reportable changes, updated enrollment
forms must be submitted within 90 days
following the effective date of the change.
CMS has stated its intention to require
deactivation for failure to report changes in a
timely manner, which may even result in revocation
of the provider’s or supplier’s billing
privileges. Deactivation is the temporary suspension
of billing privileges. Although billing
is suspended, the deactivation does not have
any effect on the provider or supplier agreement.
Specific procedures for reactivating a
provider number, including the submission of
a new CMS 855 enrollment application, are
included in the new regulations. Reactivation
in those circumstances will not require a new
survey or certification.
When billing privileges are revoked, the provider
or supplier agreement is also terminated.
Additionally, when a revocation occurs,
CMS will automatically review any related
Medicare enrollment file. For example, if a
reported owner (i.e., 5% or greater ownership
interest) is also an owner or a person in
control of another Medicare enrolled entity,
CMS will review the revocation to see if it
warrants an adverse action for the associated
provider or supplier (i.e., associated in this
case by a person with ownership in both
enrolled entities.)
Revalidation process
CMS has developed a procedure to allow it
to determine if updated information has been
promptly submitted. Under the new regulations,
CMS has established a five-year cycle
for revalidation, with the ability to perform
an “off cycle” revalidation if conditions so
warrant. The revalidation process will be
an opportunity to ensure that a provider
or supplier has remained in compliance
with Medicare requirements. In addition to
confirming the validity of the enrollment information
submitted through the revalidation
process, CMS reserves the right to perform
unannounced site visits to verify enrollment
information. Revalidation is designed to
protect beneficiaries and the Medicare trust
fund by ensuring services are received from
legitimate providers and suppliers.
CMS does not expect the revalidation activities
to be significant until 2008, and has not
yet announced how providers and suppliers
will be chosen to enter into the 5-year cycle,
though the first revalidation efforts will focus
on providers or suppliers who never previously
submitted a complete CMS 855 form.
CMS has indicated that the first priority for
enrollment contractors should be to process
new enrollment applications. Such prioritizing
of effort is intended by CMS to address
the concern expressed by providers and
suppliers regarding the ability of the Medicare
enrollment contractors to handle the
increased workload. In its final rule, CMS announced
the intent to conduct approximately
500 on-site visits to Community Mental
Health Centers and 2,800 annual visits to
Independent Diagnostic Testing Facilities.
Once the revalidation process becomes
established, the burden on providers and suppliers
should be relatively minimal. CMS has
indicated its intent to send the provider’s or
supplier’s current CMS 855 form on record
to the provider or supplier, to verify the
accuracy of the information and report any
changes to be made regarding the information
in the enrollment file.
Initial enrollment
The new regulations delineate situations in
which the initial enrollment application may
be rejected. If the application is submitted
with missing information and any missing
information or requested supporting
documentation is not submitted on time, the
application will be rejected and the applicant
will need to restart the enrollment process.
There are no appeal rights granted when an
application is rejected.
Additionally, an entity may be denied enrollment
or have its enrollment revoked when
individuals with ownership or controlling
interests have been sanctioned or convicted of
certain federal or state crimes. The new regulations
delineate the specific offenses, such
as exclusion sanctions, that will result in an
automatic rejection or revocation, and other
offenses that may result in rejection or revocation
because the offense has been determined
to be detrimental to the best interests of the
Medicare program or its beneficiaries.
Enrollment may be denied if there is a
determination, based upon the on-site review
or other reliable evidence, that the provider or
supplier is not in compliance with the Medicare
requirements. Appeal rights are granted
in this situation. If, however, the decision is
appealed, then a new application may not be
submitted until a decision is made to uphold
the original determination. If the provider or
supplier elects not to appeal the decision, a
new application may be submitted when the
time frame to appeal has lapsed.
Change of ownership
Consistent with prior requirements, if a
change of ownership involves providers, both
the buyer and seller need to submit provider
enrollment application information. Under
the new regulations, the seller risks sanctions
if it fails to complete the enrollment materials
prior to the change in ownership. When the
seller agrees to assign and the buyer agrees to
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Health Care Compliance Association • 888-580-8373 • www.hcca-info.org
September 2006
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