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An important condition of maintaining your Medicare billing privileges is to ensure that your entity enrollment record is always current.  Elements of your enrollment record that may change include ownership, practice location (all service locations), billing company information, authorized officials, medical record locations, etc.

Regulations require that physicians and non-physician practitioners, and physician and non-physicians organizations (clinic/group), report change of information such as a change in practice location, or change of ownership within 30 days.  Below is an excerpt from the regulation:

CFR424.516(d) Reporting requirements for physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations. Physicians, nonphysician practitioners, and physician and nonphysician practitioner organizations must report the following reportable events to their Medicare contractor within the specified timeframes:

(1) Within 30 days—

(i) A change of ownership;

(ii) Any adverse legal action; or

(iii) A change in practice location.

(2) All other changes in enrollment must be reported within 90 days.

Consequences of failure to report

Failing to report change in information can result in revocation of billing privileges.  Likely the first step will be a request for information from your intermediary to report changes that it has discovered need to be filed.  You will have 60 days to respond to this request.

If your billing privileges are revoked for this reason and you subsequently supply the corrected information for your records; your effective date will be the date you came back into compliance.  Therefore you will not be able to bill for services rendered during the time period you were considered to be out of compliance.

Importance of practice locations

The new version of the CMS855R (provider re-assignment of benefits) now has a section to fill out the provider’s primary service location for the group.  Obviously this is meant to cross-reference the group enrollment record to ensure the practice locations on file are correct.  If an 855R is filed with a service location that is not listed in your group enrollment record, not only will the 855R be rejected, but you also run the possibility of having billing privileges revoked for your group due to failure to report changes.

Ownership information

It is important that you list every partner/owner of your medical group on your Medicare enrollment record.  We are experiencing situations where Medicare is comparing submitted ownership information with state records of incorporation and comparing the list of owners.  If not all owners are reported on the application, Medicare can reject the application.

It is also important that you update ownership information as partners come and go.  Such changes must be reported within 30 days.

Summary

Medicare provider and group enrollment is not a “one and done” process.  You must always ensure complete accuracy for every section of the enrollment applications and report changes timely.  There is potential for losing the ability to be reimbursed by Medicare if changes are not reported.