Alice Gosfield, Episode 7: Why Medicare Enrollment Is Like Home Ownership (Because It Requires Constant Maintenance)

Why is Medicare enrollment often misunderstood as a one-time process?

Medicare enrollment is frequently misperceived as a one-time task because many believe that once the initial setup is done, no further action is needed. However, this is not the case, as Medicare enrollment requires continuous updates whenever there is a change in the information provided in the applications. This ongoing maintenance is crucial to ensure compliance and prevent issues with billing privileges.

What are the ongoing obligations for maintaining Medicare enrollment?

Once a provider is enrolled, they must regularly update their information whenever changes occur. Additionally, they must respond to revalidation requests, which typically happen every five years but can occur more frequently. These revalidations involve submitting a completely new application rather than merely updating single pieces of information.

What types of changes require updating Medicare enrollment information, and what are the timelines?

Any changes in the application information must be updated. Generally, updates must be made within 90 days of the change. However, certain changes, such as ownership changes, practice location changes, or reporting adverse legal actions, require updates within 30 days. These tighter timelines help ensure that critical information remains current.

Where do practices most often fall out of compliance with Medicare requirements?

Practices commonly fall out of compliance in two ways: failing to report one-time changes due to oversight or missing deadlines, and neglecting to respond to revalidation requests. The latter can happen if the practice doesn’t receive the request due to outdated contact information, which can lead to serious compliance issues.

How does Medicare differentiate between deactivation and revocation of billing privileges?

Deactivation involves temporarily turning off billing privileges, which can be easily corrected by addressing the issues identified. On the other hand, revocation is much more severe, often resulting from major non-compliance or actions threatening Medicare's integrity. Revocations lead to being removed from the system for one to ten years, significantly impacting a practice's ability to operate and generate revenue.

What happens to a practice's cash flow when its Medicare enrollment status is disrupted?

When a practice's billing privileges are deactivated or revoked, it cannot submit claims to Medicare, leading to significant cash flow issues. This can jeopardize the practice's financial health, especially if it heavily relies on Medicare revenues, highlighting the importance of maintaining compliance to prevent such disruptions.

What is the revalidation process, and where do practices encounter difficulties?

Revalidation occurs every five years or more frequently, where the Medicare Administrative Contractor (MAC) requests updated information. Problems arise when practices fail to update contact information, causing them to miss revalidation requests and potentially leading to deactivation or revocation.

Can you provide an example of outdated or incomplete information causing problems later on?

In one instance, a practice faced revocation because a former physician, whose information was never removed, had their license revoked elsewhere. CMS assumed the practice failed to report this, highlighting how outdated records can cause significant compliance issues. This example underscores the importance of keeping information current to avoid similar situations.

How should a practice manage Medicare enrollment to avoid compliance issues?

Practices should designate someone knowledgeable about regulatory requirements to handle updates. Regularly reviewing and updating information, ideally annually, is crucial. This approach prevents outdated information from causing problems and is akin to routine maintenance tasks, like changing batteries in smoke detectors, to prevent bigger issues.