CMs-855 Enrollment: Advanced Topics

Recorded Webinar | Duane C. Abbey | From: Nov 30, 2017 - To: Dec 20, 2017

Enrolling in the Medicare program involves the various CMS-855 forms.  There are now seven different forms that must be used by different providers of healthcare services or products.  These forms are long, detailed and sometimes confusing.  Not only must they be filed initially for given provider, they must be maintained and updated as appropriate.  Due to the increasing complexity of healthcare delivery systems, providers, such as integrated delivery systems or large multi-specialty clinics, may have to maintain hundreds of these forms.  The Medicare program uses a revalidation process to periodically require all healthcare providers to resubmit their various 855 forms in order to assure that compliance is being maintained.  Over time the use and guidance of the enrollment process continue to morph even though there is no change in guidance.  This occurs through interpretations and clarifying guidance.

This workshop addresses selected issues for the main six CMS-855 forms.  In extremely simple cases, filing and maintenance of the CMS-855 forms is straightforward.  Most healthcare providers are part of a larger, often integrated delivery system that complicates Medicare enrollment as well as enrollment with private third-party payers.  In this workshop, due consideration is given to all of the enrollment forms relative to:

  • Business Structuring,
  • Practice Locations,
  • Tax Identification Numbers,
  • National Provider Identifiers,
  • Opt-Out Physicians and Practitioners,
  • Provider-Based Clinics/Operations.
  • What are these CMS-855 forms?
  • What is this newer CMS-855-POH form?
  • Why is the Medicare Program so sensitive to enrollment?
  • Where do I find the official regulations for Medicare enrollment?
  • What do I need to do to understand the way our business(es) have been structured?
  • What are these TINs? What relationship do they have to Medicare enrollment?
  • Are there any problems with the Cycle 2 revalidation process?
  • How can we check to see who needs to be revalidated?
  • Are there really on-site audits relative to enrollment?
  • What are these opt-out physicians and practitioners?
  • How is Part D coverage involved with these CMS-855 forms?
  • How are we supposed to keep track of all these CMS-855 forms?
  • What are the compliance risks relative to Medicare enrollment?
  • How do provider-based clinics and operations complicate the enrollment process?

Objectives of the session:

  1. To review the Medicare enrollment process through the use of the various CMS-855 forms.
  2. To briefly review the CMS Conditions for Payment (CfPs).
  3. To appreciate the Medicare concerns surrounding billing and payment for services and supplies.
  4. To review organizational and business structuring that is controlled by state law.
  5. To review organizational structuring changes such as with provider-based clinics.
  6. To discuss the challenges with identifying practice locations.
  7. To review the purpose and use of the six main CMS-855 forms along with specific problem areas.
  8. To understand the concept of opt-out physicians and practitioners.
  9. To appreciate how opt-out physicians can and/or should enroll in the Medicare program.
  10. To appreciate how Part D coverage is impacted by the enrollment process.
  11. To understand the revalidation process and associated challenges.
  12. To appreciate how other required reporting, such as the NPIs and Provider-Based reporting connect with the Medicare enrollment.
  13. To recognize the need to develop organizational resources to maintain multiple CMS-855 forms.
  14. To appreciate the proper use of the Internet-based PECOS process.
  15. To appreciate current and anticipated changes for maintaining billing privileges with Medicare.
  16. To work through several case studies.
  17. To recognize the need to establish contact with knowledgeable personnel at the MAC and/or RO.

Agenda of the session:

  1. Introduction
    1. Conditions for Payment – 42 CFR §424
    2. Definitions – Provider vs. Supplier
    3. Claims Filing Process
    4. Reassignment of Payments
    5. OIG Investigations Concerning Fraudulent Billing
    6. Revalidation and Billing Credentialing
    7. Opt-Out Physicians and Practitioners
  2. Review of the CMS-855 Forms
    1. CMS-855-A
    2. CMS-855-B
    3. CMS-855-I
    4. CMS-855-O
    5. CMS855-R
    6. CMS-855-S
    7. How the CMS-855 Forms Relate to Each Other
  3. Special Areas of Concern
    1. Business Structuring Analysis
    2. National Provider Identifiers- NPIs
    3. Tax Identification Numbers – TINs
    4. Practice Locations
    5. Dispensing Locations for DME
    6. Provider-Based Clinics
    7. Opt-Out Physicians/Practitioners
    8. Identifying Individual Owners
    9. Identifying Organizational Owners
  4. Revalidation Process
    1. Revalidations Cycles
    2. Cycle 1 Process
    3. Cycle 2 Process
    4. Determining Status and Notification
    5. Time Frames for Completion
    6. Risk Levels
    7. On-Site Visits
  5. Addressing Changing Organizational Structuring
    1. Impact of Organizational Structuring on Enrollment
    2. Integrated Delivery Systems
    3. Multi-Specialty Groups
    4. Provider-Based Clinics/Operations
    5. Maintaining NPIs and TINs
    6. Other Related Reporting Requirements
  6. Case Studies
  7. Future Requirements for Conditions for Payment

Who should attend?

  • Claim Filing Personnel
  • Coding and Billing Personnel
  • Compliance Personnel
  • Financial Personnel
  • Accreditation and Licensing Personnel
  • Physicians, Non-Physician Practitioners
  • DME Suppliers
  • Clinics
  • Cost Report Personnel
  • Other Personnel Interested in Billing Privileges with the Medicare Program

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