We receive many inquiries from Chiropractic practices that are partnering with physicians and mid-level providers to convert their chiropractic practice to a multi-specialty medical clinic providing primary care services, walk-in medical care, chiropractic care, and provide limited durable medical equipment.
The first, and seemingly most important, network for these practice to enroll with is Medicare. Let’s pause briefly to explain an important term that you will hear in dealing with Medicare. You will hear and read reference to a “Medicare PTAN”. PTAN stands for Provider Transaction Access Number. This is your “Medicare ID”. You will have a PTAN for each individual provider as well as a group PTAN identifying an entity. PTAN’s are required for filing claims to Medicare as well as communicating with your local Medicare contractor on claims related issues.
To begin the enrollment process starts with submitting the correct enrollment applications for your entity along with your providers. The group/supplier application is the CMS855B and the individual provider application is the CMS855I. The CMS855R “re-assigns” benefits from an individual provider so that payments are made to the group/supplier instead of the individual provider. There are other required forms such as the CMS460 to elect participation in the program, and the CMS588 to setup your electronic funds transfer to receive Medicare payments. You will need to submit all of these forms along with appropriate supporting documents.
An alternative to paper application forms is PECOS. The online Medicare enrollment system PECOS can assist in turning around your Medicare applications more quickly. You can now e-sign your Medicare applications through PECOS making the process even quicker.
A typical enrollment process for a Chiropractor owned medical clinic may include:
- Filing an 855B listing the owner as the D.C.(s)
- Filing an 855I for each medical provider
- Supporting documentation requirements vary by type of provider
- Filing an 855R for each medical provider to reassign benefits to the group
- Filing a CMS460 form to elect to participate in the Medicare program
- Filing a CMS588 to establish Electronic Funds Transfer for your Medicare payments
Below is a checklist of key items that you will need in order to complete the Medicare enrollment application process for your new group.
- Type 2 NPI and Tax ID for the legal business entity
- Copy of your CP575 to verify your legal business name and tax id#
- Full name, place of birth, date of birth, social security number, NPI, and Medicare ID of ALL owners and managing employees of the enrolling group
- Letter from your bank on their letterhead signed by a bank officer verifying your bank account. It is very important that your letter include the following elements:
- Your business name exactly as it appears on your CP575
- The type of account (business checking, business savings, etc)
- The bank routing #
- Your account #
Include DME at your new multi-specialty clinic
Becoming a DME provider as some specific requirements. Chiropractors are not eligible providers under the Medicare program to order or provide DME as part of their practice. In order for a Chiropractor to become a DME supplier, they must enroll as a free standing retail operation and must meet the accreditation and surety bond requirements. Read more about those requirements here.
Physicians, Nurse Practitioners, Physician Assistants, and certain other providers are eligible to order and provide DME as part of providing their professional medical services and are exempt from the accreditation and surety bond requirements for enrolling as a DME supplier.
If you are enrolling as a DME provider with Medicare and wish to avoid undergoing accreditation and obtaining a surety bond, then your practice may provide DME strictly to the patients treated in your clinic by a physician or eligible mid-level provider. It is imperative that you understand this condition and fully comply with the Medicare regulations. Since your DME enrollment application will be submitted with the owner being a Chiropractor, your Medicare carrier may contact you to clarify that you will only provide DME to patients being treated by eligible providers in the medical practice.
If you plan to sell DME with the new medical practice and you currently have a DME number with Medicare in your chiropractic practice, it is important to note that you cannot have another DME number for the same physical location. You can, however, transfer your DME number from your chiropractic entity to your new medical group. The application process for this situation is different than applying for a new DME number, so be sure to start the process correctly.
Below is a list of key items and information that you will need in order to complete the DME enrollment application:
- Current group/supplier Medicare PTAN
- Physician and or eligible mid-level provider enrolled and assigned to your group PTAN
- Professional liability insurance including product liability for the entity
- Specific list of items that you will sell (click here for the list)
- Have posted hours of operation for the clinic providing DME showing availability of at least 40 hours per week
- List of all owners including other entities along with specific identifying information such as tax id for entities, Medicare PTAN, NPI, SSN, Date of birth, place of birth
- Billing agency information including tax id if you utilize the services of a billing company
Click here for a complete list of supporting documents required for the Medicare DMEPOS application.
An important part of the DME application is that an inspector will visit your clinic as part of the process. The inspector will look to see that the clinic is operating, that your inventory is stored and matches the items you elected to provide in your application, that your hours are posted, and various other requirements. They are basically making certain that you have a legitimate business operating as described in your application.
Commercial Insurance Enrollment
Each commercial carrier has their own enrollment/contracting process. Some require submitting paper applications, while others utilize web applications or CAQH to obtain information electronically. Either way, there will be some paperwork to be completed and much follow up to be done during the process.
Group vs Individual Contracts
Group contracts are the preferred method of contracting with commercial carriers. Some carriers will extend a group contract when there are two or more providers in the new group, while others won’t contract as a group until a threshold is met such as 20 or more providers. In cases where carriers won’t offer a group contract, they will only extend individual contracts. This varies widely among payors and geographical areas.
Individual contracts are common and not at all an operational hindrance for a small group practice. Individual contracts will still be linked to your entity and tax id with payments coming to the practice. The major difference is that an individual contract is “portable”, meaning that if a physician leaves one group, his/her contract can move with them to be assigned to another entity and tax id. An individual contract can benefit you if you are hiring a provider already contracted with a plan because the provider can move the contract to your group.
Having a group contract in place does not change the credentialing requirements of a payor. We have encountered many who have been under the impression that when you have a group contract, you only need to call the carrier and add a new provider to the group contract. The process, however, is not that simple. There are two specific processes that are completed during the enrollment of a new provider. They are 1) credentialing and 2) contracting. ALL providers must go through the credentialing process. If a provider is already credentialed with a plan, it may reduce the time or eliminate the need for the first step of credentialing. It takes a call to the plan to find out what there process is and what paperwork is required to attach the already credentialed provider to the group contract. The contracting process is a bit quicker for group agreements, but the plans contracting department must still link the provider to the group contract after approved by the credentialing committee.
Mid-Level Providers and Commercial Insurance Networks
Not all commercial plans separately credential and contract with mid level providers. Many plans only allow reimbursement for mid-level services when employed by a physician practice and billed under the supervising physician. In these cases, there is no credentialing or contracting required, you simply bill for services incident-to the supervising physicians services. Your billing staff should be fully aware of these requirements and is your best source for explaining this process.
This can also impact whether or not a “group” contract is extended. If you have a physician and an NP in your group but a commercial plan doesn’t credential/contract with NP’s, then you don’t have at least 2 providers to form a group.
Physician Assistants, typically are more often not credentialed and can only participate with plans as an employee of a physician. This is specifically the case for Medicare, and is normally encountered with commercial plans. Nurse Practitioners are able to separately enroll with Medicare and more able to credential/contract with some commercial plans than PA’s.
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nCred can help make your enrollment process less of a hassle. Our team of credentialing specialists can handle all the paperwork and follow up necessary to get your practice enrolled with the plans that are important to you. Call us today at 423.443.4525 opt#2 to discuss your needs, or fill out our request for information form and we’ll have a representative contact you for more information.
