Medicare Compliance & Reimbursement

You could advance 4 months' credit to Medicare for new doctors.

If your carrier is First Coast Service Options or Trailblazer Health Enterprises, you could be waiting a third of a year or more for provider numbers.

Heads up: Enrollment problems with some carriers don't affect just new physicians. If some of your physicians haven't updated their information since November 2003, then the carriers may force you to resubmit a complete 855 application form, leaving you in the same mess.

A "perfect storm" of bureaucratic problems has slowed enrollments at some carriers to a crawl, say experts. For one thing, the Centers for Medicare & Medicaid Services (CMS) rolled out a new 855 form to make room for the National Provider Identifier (NPI) number. For another, CMS asked carriers to start making physicians re-apply if they updated any of their information and they last enrolled prior to fall 2003, when CMS rolled out the Provider Enrollment, Chain and Ownership System (PECOS).

Trailblazer recently updated its Web site to tell providers to expect a clean enrollment application to take 90 days--instead of the 60 days that Medicare normally requires. But this longer timeframe is still too optimistic, say providers.

Reps from Trailblazer have been telling providers they won't even look at any applications apart from the ones that new providers submitted at least 120 days ago, according to Pamela Stevens, director of patient accounting for National Vascular Care in Rosemont, PA. "They'll just say they're short-handed" if providers ask questions, she adds.
The carrier has hired temps to staff the phones, but they don't know the answers to any serious enrollment questions.

Even though CMS isn't officially requiring carriers to start "revalidating" all enrollment forms for providers who aren't in the PECOS system, some carriers have been overzealous, says Stevens.

Back in October, First Coast had 7,000 physician applications piled up, but now that number has more than doubled to 15,800, according to Leslie Witkin with Physicians First Physician Consulting in Orlando, FL.

"We can't send any claims until the provider number is issued," says Karen Hurley, president of HPMSI in Waldorf, MD. "Right now we have three months of Medicare claims for one provider that we're holding."

Keep Up The Pressure

What to do: Experts suggest a few approaches to this ongoing disaster.

1) Providers need to keep demanding that CMS step in and fix these problems. The last time these sorts of enrollment delays happened, when PECOS was first instituted, CMS gave extra resources and guidance to carriers to reduce the backlog. That hasn't happened this time.

Even though the myriad of instructions and mandates from CMS caused these logjams, CMS officials persist in accusing providers of making mistakes on their application forms, say consultants.

Do this: If your practice has to turn away Medicare patients because you can't credential some of your physicians, make sure the beneficiaries understand the problem and complain to the American Association of Retired Persons, providers suggest.

2) Find a creative way to have your physicians  "start" earlier. First Coast won't allow you to submit applications for a new provider more than 30 days before his/her start date. So Witkin encouraged one practice to bring on a new doctor early on a part-time basis.

Legally, the "start date" is the day the doctor sees a Medicare patient for the first time, Witkin explains. So instead of having this doctor start on July 1 as planned, the practice had her come in as a part-timer starting May 1. That way, the practice could put her application in as of April 1.

3) Be prepared to re-apply for old physicians. If you have a doctor who last applied before late 2003, then your carrier may require you to submit a whole new application for that doctor. Be proactive and submit those re-applications before you have to update those doctors' information.