Tuesday, June 2, 2009

Medicare Enrollment Rules - Important Changes On Retroactive Billing And Maintaining Documentation

Health care providers (physicians, providers and suppliers) should be aware that new Medicare enrollment rules that recently took effect limit physicians’ ability to retroactively collect from Medicare. There are also new rules regarding maintaining ordering and referring documentations.

The new rules, which took effect on April 1, 2009, shorten the time frame during which these providers can bill retroactively for Medicare services after enrolling or otherwise changing their enrollment status. Under the new rules, enrollment will be retroactive to 30 days prior to the receipt date of a complete application, or for new physicians joining Medicare, the date the physician saw his first Medicare patient, whichever is latest.

This change could result in providers not being paid for services to Medicare beneficiaries if they do not submit applications or other status changes (such as change of ownership, change in location or a final adverse action) within 30 days. For example, if a medical supplier changes location on January 1 but does not submit an address change to Medicare until June 1, the supplier could lose 4 months worth of Medicare payments. The supplier can bill retroactively to May 1 (30 days prior to submitting the address change), but he cannot bill for any supplies provided to beneficiaries seen during the 4 month period after the move, but before the change of address was filed.

The new rules also require providers to alert Medicare of a change in practice location within 30 days, or risk expulsion from Medicare for up to two years. It is imperative that providers submit new applications and reportable changes accurately and immediately in order to avoid such payment gaps. To avoid unnecessary delays, it is recommended that providers use Medicare’s web-based PECOS enrollment system.

Requirements for maintaining ordering and referring documentation

Under these rules, carriers may revoke the billing privileges of any provider or supplier that fails to comply with Medicare’s ordering and referring documentation requirements as specified in 42 CFR 424.5216 (f). Such revocation is also possible in cases where the physician or non-physician practitioner fails to maintain written ordering and referring documentation for seven (7) years from the date of service. Off site or electronic storage are acceptable as long as the records are readily retrievable.

For more information, see this notice from Palmetto:

Any questions or comments should be directed to: tgreen@greenassoc.com. Tracy Green is a principal at Green and Associates in Los Angeles, California. They focus their practice on the representation of licensed professionals and businesses in civil, business, administrative and criminal proceedings, with a specialty in health care providers.


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