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Provider Enrollment: Important Reminder From CMS

Guest Article by Elizabeth E. Hogue, Esq.


Providers are quite familiar with Forms 855, and requirements for filing them to obtain and retain enrollment in the Medicare Program. Anecdotally, however, it seems that many providers are not diligent about filing them as required. In addition, the Forms are generally unclear, so it is difficult for providers to complete them appropriately. The lack of clarity is complicated by the facts that different subcontractors process these Forms and individual reviewers may require different responses. Despite these challenges, now is the time for providers to pay careful attention to the completion of these Forms.

One indication that completion of Forms 855 is becoming serious business is increasing emphasis by the Centers for Medicare & Medicaid Services (CMS) on preventing providers who pose risks from entering or continuing as providers in the Medicare Program. As a matter of policy, CMS now emphasizes prevention and discontinuation of the enrollment of problem providers instead of chasing providers after payments have been made, so-called "pay and chase."

Another indication that increased attention is appropriate is that CMS has combined Provider Enrollment with Program Integrity, i.e., fraud and abuse prevention and enforcement. This change makes it clear that CMS now regards provider enrollment as an important tool to prevent fraud and abuse.

The importance of filing timely, accurate Forms 855 was most recently emphasized in MLN Matters Number SE1617 issued by CMS. This MLN Matters article is directed to all providers and suppliers that submit claims to Medicare Administrative Contractors (MACs) for services to Medicare beneficiaries and says:

Failure to comply with the requirements to report changes in your Medicare enrollment information could result in the revocation of your Medicare billing privileges. This article does not establish any new or revised policy, but serves as a reminder to comply with existing policy.

The article goes on to remind providers that report the following changes in their enrollment information to their MACs or the National Supplier Clearinghouse for durable medical equipment suppliers within 30 days of the change:

  • A change in ownership
  • An adverse legal action
  • A change in practice location

All other modifications to information in Forms 855 must be reported to the MACs or National Supplier Clearinghouse within 90 days of the changes.

CMS may have issued this article, in part, based on the conclusions that the OIG reached in a report entitled "Medicare: Vulnerabilities Related to Provider Enrollment and Ownership Disclosure." Here is what the OIG found, based on its review:

Over three-quarters of Medicare providers in our review had owner names on record with CMS that did not match those that providers submitted to OIG. Further, nearly all providers in our review had owner names on record with CMS that did not match those on record with State Medicaid programs. The prevalence of nonmatching owner names raises concern about the completeness and accuracy of information about Medicare providers' ownership. It also demonstrates that provider may not be complying with the requirement to report ownership changes to CMS...

Consequently, the OIG recommended that CMS take the following action:

  • Review providers that submitted nonmatching owner names and take appropriate action.
  • Educate providers on the requirements to report changes in ownership.
  • Increase coordination with State Medicaid Programs on the collection and verification of provider ownership information in the Medicare and Medicaid Programs.

What should providers and suppliers do now? Providers and suppliers should review the Forms 855 they have recently filed, the information in the PECOS system and information on file at State Medicaid Programs, if providers also participate in these programs. If changes are needed, Forms 855 with complete, accurate information should be filed immediately and Medicaid Programs should be notified of all changes. In view of their complexity, it may also be helpful to have these Forms reviewed by knowledgeable legal counsel prior to submitting them.


©2017 Elizabeth E. Hogue, Esq.  All rights reserved.

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