May 16, 2007
Hospitals, clinics, and other healthcare providers face a myriad of reporting requirements. For billing and claims filing, three areas that have developed in recent years require careful consideration but are often overlooked in a facility's work plan:
- CMS-855—Medicare enrollment application
- National provider identifiers
- Provider-based status
As the April 2007 Revenue Cycle Strategist newsletter reports, it's easy to consider the reporting of these change updates as incidental tasks that can be performed quickly with little personnel time involved. However, depending on the size and scope of your healthcare organization, these updates may involve a lot of work to meet these reporting requirements. Also, there may be a significant amount of information and documents that need to be gathered and organized for quick accessibility.
CMS recently released an updated rule concerning gaining and maintaining billing privileges with the Medicare program. The April 21, 2006, Federal Register discusses these changes to the Code of Federal Regulations. The newly revised CMS-855 forms were not a part of this Federal Register although the new forms have now been released. Note that the old forms contain more instructions and background information on completing the forms. Be sure you retain copies of the old forms for reference.
CMS-855
Five different CMS-855 forms are used under different circumstances:
- CMS-855A—Institutional Provider
- CMS-855B—Clinics/Group Practices and Certain Other Suppliers
- CMS-855I—Physicians and Non-Physician Practitioners
- CMS-855R—Reassignment of Medicare Benefits
- CMS-855S—Durable Medical Equipment, Prosthetics, Orthotics, and Supplies Suppliers
These forms can become quite complicated with significant amounts of additional information required. For example, individuals who have control over a hospital or clinic must report all of their relevant personal information right down to their Social Security numbers. Hospitals also will find that multiple, interrelated CMS-855 forms will need to be filed and then maintained. For example, a hospital may own provider-based clinics, employ physicians and in some cases also be a DME supplier. In such circumstances, all five CMS-855 forms may need to be completed, and particular forms may need to be used multiple times.
In general, the CMS-855 must be updated within 90 days of any general change and within 30 days for changes in ownership, management, and/or financial control. These time frames may appear to be reasonable, but given the influx of changes at hospitals, it is critical to ensure these changes are processed on time.
National Provider Identifiers
On May 1, 2006, CMS required the use of the new National Provider Identifiers (NPI) numbers in filing the CMS-855 forms. Although the NPIs are not being used for billing purposes until May 23, 2007, hospitals and other providers must still obtain their NPIs before actual use in filing claims.
Obtaining an NPI is not an onerous process, but hospitals need to determine how many NPIs to obtain by carefully analyzing their organizational structure. Again, for a hospital that may have provider-based clinics, an ambulatory surgery center, a home health agency, and other types of services, this business organization analysis could be complex. Although there are a limited number of data elements in applying for an NPI, any changes need to be updated in a timely fashion.
Provider-Based Status
The provider-based rule has been developed and implemented over the past decade with a number of convolutions. One of the requirements under the provider-based rule is that hospitals must report any changes that might affect their provider-based status.
Exactly how broadly or narrowly this rule is to be interpreted, and then to whom and how these changes are to be reported, are somewhat ambiguous. Nevertheless, this reporting requirement must be addressed. For example, your hospital may start a new pain management clinic inside the hospital. This is certainly a provider-based operation, but does this type of change need to be reported? Will this change be reported through the CMS-855 process? Give yourself plenty of time to resolve such questions with your CMS contractor.
Plan Realistically
It's wise to take the time and trouble to fully understand these reporting requirements, the amount and type of information required, and the timing requirements for reporting. The effort spent in ensuring you have the personnel and organizational infrastructure to fully meet these reporting requirements will minimize the administrative headaches of keeping your CMS billing privileges up to date.
SOURCE: Duane C. Abbey, Remember to Report Changes, April 2007, Revenue Cycle Strategist
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CMS' plan to adopt severity-adjusted DRGs is the most significant change that has been made to the Medicare hospital inpatient prospective payment system since it was created in 1984. To help your organization prepare, HFMA has pulled together a comprehensive list of resources, including articles and PowerPoint presentations, addressing issues related to Medicare DRGs. View all of the tools and resources now; you can also sign up to automatically receive updates as more information and tools become available.
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HFMA Wants You to Know ISSN: 1540-0697. Volume VI, Issue 10. Copyright 2007, Healthcare Financial Management Association. All rights reserved.