1. Proposed Changes to Medicare Billing Privileges

CMS has introduced a proposal that should grab the attention of credentialing and enrollment professionals. If finalized, it would change select rules for Medicare billing privileges. The proposed rule, in CMS’ 2020 Medicare Physician Fee Schedule, recommends applying Medicare enrollment approval and revocation rules for opioid treatment programs to all physicians and other eligible professionals (e.g., advance practice nurses, PAs, and others) for a variety of reasons. It would affect providers who have reassigned their billing privileges to a group practice and who have a minor licensing matter that CMS determines puts the Medicare trust fund or its beneficiaries at risk of harm.

Specifically, if the rule is finalized, it would allow CMS to revoke the Medicare billing privileges of any provider who’s been “subject to prior action from a state oversight board, federal or state healthcare program, Independent Review Organization (IRO), or any other equivalent governmental body or program that oversees, regulates, or administers the provision of healthcare with underlying facts reflecting improper physician or other eligible professional conduct that led to patient harm.” Currently, providers are only required to report final adverse actions.

For enrollment professionals, the proposed rule likely would raise the stakes to ensure that information about licensing matters are identified when initially completing the application forms and throughout the entire employment period. Becker’s Hospital Review also reports that the manner of reporting a minor licensing board action will be key to avoiding an otherwise qualified professional from not being granted billing privileges in the first place, or losing privileges.

2. Potential Problems in PECOS Release 7.37 for Group Practices

CMS issued two items pertaining to the Provider Enrollment Chain Ownership System (PECOS), which is the online, alternative to the paper process (CMS-855 form) to enroll providers or supplier organizations into Medicare. Using PECOS, providers and their organizations can also track and update their applications, complete revalidations, and voluntarily withdraw from Medicare.

CMS implemented PECOS Release 7.37 on June 30, 2019 to help bring efficiencies to Medicare Administrative Contractors (MAC) and providers who use PECOS. Most elements of the release rolled out successfully; however, a component associated with changes made to existing and new group reassignments (usually associated with clinic/group practices and certain other provider classifications) was found to have issues following the implementation.

As a result and to correct the issues, data that flows from PECOS to the Multi-Carrier System (MCS) for these types of changes are delayed for all MACs. This change doesn’t affect a provider’s ability to submit enrollment applications. However, attempts to enroll with the Electronic Data Interchange (EDI) could be delayed. CMS will release an update when the issue is fixed to allow EDI enrollments to occur. In addition, any claims submitted from an approved enrollment may need to be resubmitted after the fix, due to the system not recognizing the provider’s NPI/PTAN in the claims system. Again, CMS will advise when the fix is completed.

Reassignments can still be submitted, although EDI and claims associated with any changes may need to be resubmitted at a later date. There’s no disruption of any other type of enrollment activity as a result of the issues..

Improvements in PECOS Release 7.37 include:

  • The user name of the person submitting the application will be displayed.
  • PECOS will match the new 855R form changes.
  • E-signature access links will be displayed on the home page in the “helpful links” section.
  • An MDPP location can no longer be associated to an organization code of a recognition status that is no longer active.
  • The system now requires the employer PIN for a PA and the system now differentiates between ASC and NonASC values for the Reasonable Charge Locality Code field as part of continuing effort of the MCS Lockdown project.
  • Users can link and add the contact person information to the individual practitioner enrollment through the 855R form.
  • Users can add columns to the PECOS Bi-weekly O&R extract to capture physicians and nonphysicians eligible to order and refer for HHA, PART B, DME and PMD services.
3. Multi-factor Authentication Comes to I&A & NPPES

Effective now (as of September 1, 2019), CMS has implemented multifactor authentication (MFA) in PECOS. With this change, providers log in to PECOS’ Identity and Access (I&A) System as usual but will use a second-factor authentication process to obtain a verification code. For time-sensitive changes to PECOS, it’s recommend users log in to PECOS sson after the change to ensure contact information used to deliver the verification codes is current. In December, MFA also will be implemented for the National Plan and Provider Enumeration System (NPPES), the primary source for National Provider Identifiers.