ENEWS | VOLUME 1, ISSUE 1 | MAY 2010

enewsMedicare 30-Day Retro RuleA typical standard operating procedure in many practices when adding new physicians is to phase in their schedule as they become credentialed by each payer. Traditionally, new physicians were able to see Medicare patients immediately per the Medicare guideline that allowed for a practice to retro-bill for Medicare patients treated up to 27 months before the doctor was officially credentialed.

That has changed and since April 1, 2009, practices can only retro bill for Medicare patients seen 30 days prior to the date the approved credentialing form was filed.

Potential Problems:

The Enrollment Application Medicare does not allow providers to submit an enrollment application more than 30 days prior to his/her start date. It is now more important than ever that your billing office be informed of any new providers joining the group well in advance to his/her start date. Preferably, new providers should submit supporting documents and signature pages to their billing office during the credentialing process with the hospital. This allows the billing office time to submit the Medicare application prior to performing any services. Services provided more than 30 days prior to Medicare receiving an enrollment application will not be paid. This makes the potential for lost income extremely high.

Group Enrollment When a new group enrolls with Medicare, the group application and each individual provider application must be submitted together as a packet to receive the same effective date. Any

Medicare enrollment applications turned in to your billing office after the initial packet has been sent will have to be held until the group application is approved and will be submitted at that time. An application can not be sent to Medicare while the initial group packet is processing as there is no assigned group number (PTAN) to link to the stray application.

It takes 30-45 days for a group to be approved by Medicare, after which the held application(s) can be submitted. The held applications can then receive an effective date with a maximum

retro of 30 days prior to receipt by Medicare. Any Medicare patients treated more than 30 days prior to the effective date for the late enrollee(s) will not be paid.

Another potential enrollment problem involves providers who enroll with Medicare, are approved but do not bill any Medicare charges within 15 days of their effective date. Due to this inactivity, their Medicare number is then deactivated and they have to start the process all over again. Enrolling with Medicare using a start date considerably earlier than your first scheduled shift can actually harm you and prolong the enrollment process.

Furthermore, billing offices are noticing a significant increase in the number of “Development” letters targeting deficiencies in enrollment documents for applications submitted since the new 30-day-retro rule went into affect. These actions to stall the enrollment process are frustrating and places considerable financial burden on groups where large sums of money are being held due to enrollment obstacles.

Onine Enrollment Medicare implemented an online enrollment process called PECOS (Provider Enrollment,

Chain and Ownership System) to help new members navigate through new credentialing protocols, with an online system available for physician practices. It is designed to reduce

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It is now more important than ever that your billing office be informed of any new providers joining the group well in advance to his/her start date.

ENEWS | VOLUME 1, ISSUE 1 | MAY 2010

enewsprocessing time but has been found in some cases to actually prolong processing and create problems with retro billng dates.

Currently when a paper application is sent to Medicare it includes an application, supporting documents and signature pages. Medicare stamps the completed packet as received the day it arrives in their mail room.

Now that providers can enroll online the application has become a two-part process.First the application is completed online and submitted with all the supporting documents. An initial confirmation is received at the time of electronic submission which opens the 7 day window to complete the second part of the application related to the physician signature pages. The signature pages can not be submitted electronically and must be mailed and received by Medicare within 7 days of the electronic submission or the application will be rejected. To ensure that signature pages

arrive within this time frame I recommend that the person submitting the application have them on-hand before completing the online documents.

In addition to the retro-billing component for new and re-enrolling physicians, doctors are required to alert Medicare contractors within 30 days if their practice has changed location. Failure to do so may result in a physician’s ineligibility to treat and be reimbursed for Medicare patients for up to TWO YEARS!

To add to enrollment difficulties, some State Medicaid programs and other private insurances are adopting the same Medicare enrollment guideline These new rules could become the standard and not the exception in the health care industry.

1. If you have a new physician coming (or will in the future), get familiar with the changes in Medicare credentialing now.

2. Make sure you have a good system in place to communicate between credentialing staff, schedulers and billers. This way everyone knows which patients the new physician is treating and billing every step of the way.

3. If the new physician is going to treat patients at no charge, make sure everyone at the practice and the patients themselves understand the special circumstances.

Steps to take when adding new physicians