portable x-ray medicare enrollment basics jan. 2020 webinar portable … · considered to be a...

Portable X-ray

Medicare Enrollment Basics

For AMERICAN PORTABLE DIAGNOSTIC ASSOCIATION

RCN Consulting Solutions, LLC January 29, 2020

Introduction

Our webinar today is intended to provide a glance at the basics of Portable X-ray Medicare Enrollment and an overview of the most common Enrollment issues.

1. Review Portable X-ray enrollment forms; 855B, 588, 460

2. Explore benefits of PECOS vs paper application

3. Overview of 855B Portable X-ray Medicare enrollment information with the

most common errors

4. Analyze Ownership, Managing & Financial Control; Organizations &

Individuals

5. Tips to help maintain an accurate Medicare Enrollment.

RCN Consulting Solutions, LLC

What are the basic Medicare enrollment

forms that apply to Portable x-ray?


CMS 855B for Portable X-ray Provider Enrollment

CMS 588 for Electronic Funds Transfer Authorization

Agreement

CMS 460 for Participating Provider Agreement

What is a CMS 855B and Who should

submit this form?


A CMS 855B form is a Medicare Enrollment application filed

by Clinics/Group Practices and Certain other Suppliers using

either method below:

Internet based PECOS or

The paper enrollment application process

Example of those submitting this form are

organizations/groups that plan to bill Medicare Part B such as:

A medical practice or clinic

IDTF,

PXR providers,

Ambulance Service,

Independent laboratories

Reasons to file an 855B


INITIAL/NEW APPLICATION

If you are enrolling in Medicare for the first time

If you are Already enrolled with Medicare but are establishing a practice location in another fee-for-service contractor’s jurisdiction.

If you are enrolled with a Medicare fee-for-service contractor but have a new or change of a tax ID number.

ENROLLED MEDICARE PROVIDERS/SUPPLIERS

Reactivation

Voluntary Termination

Change of Ownership

Change of Information

Revalidation

What is a CMS 588 form and when do Providers

initially file and/or update this form?


CMS 588 is an Electronic Funds Transfer Authorization Agreement-allowing funds to be directly deposited in the Provider’s Financial Institution Account and is filed and/or updated when: A Provider is enrolling in Medicare for the first time - (a new 588

is filed with initial 855B)

Provider Change of Ownership

Provider Change of Practice Location

Provider Change of Bank information

Provider has a new TIN

Any change in provider information such as Company name

Contact Person

Identification information-email, phone #, NPI

Change in Authorized Official

What is a CMS 460 form and When do

Providers file this form?


A CMS 460 form is a Medicare Participating Provider

Agreement and is filed when:

A Provider decides to accept Medicare assignment-meaning

that the Provider is requesting direct Part B payment from

Medicare.

Provider will accept the MAC approved charge as the full charge

Provider shall not collect from the beneficiary –or other person – or

organization for COVERED services more than the deductible &

coinsurance.

New providers enrolling in Medicare

Non participating Medicare enrollees that decide to participate

During revalidation and when making updates to enrollment

What is PECOS?


PECOS is the Internet-based Provider Enrollment Chain

and Ownership System

PECOS can be used instead of paper enrollment (i.e.

cms 855B) to:

Submit initial enrollment

View or change enrollment information

Track enrollment application through web submission process

Reactivate an existing enrollment record

Withdraw from the Medicare Program

Submit a Change of Ownership of the Medicare-enrolled

provider

What are the Benefits of using PECOS vs

Paper Enrollment?


Benefits of using PECOS vs Paper enrollment

Faster than paper processing (45 days vs 60 days for

paper)

Tailors the process to request only information

relevant to YOUR application

Checks for errors before submission, allows

documents to be uploaded

No mailing of forms, paper signing, or mailing

documents


How Accurate is your

Medicare Enrollment

Information?

Section 2 B1 Supplier Identification Information Legal Business Name

Must be exact name as Tax documents, state filing records, NPPES records

Use of former legal business name, or DBA must be listed under Other Name

COMMON ERRORS: Not updated following any legal changes Reported name does not match legal documents and/or other filed forms Not reporting a DBA name

Type of Organizational Structure

Identify Provider as a Corporation LLC, Partnership, Sole Proprietor

COMMON ERRORS: Not reported accurately (LLC vs Corp) Reporting Incorporation date when Provider is not a corporation Changes not reported

Section 2 B3 Correspondence Address Provides a direct contact for sending important letters and documents

COMMON ERRORS: Missing suite/room numbers, incomplete zip code (missing last 4 digits) Reporting a billing, management co., chain home office, or

representative(attorney)’s address


Common errors in Reporting Supplier

Identification Information on 855B

Section 3 –Reporting Final Adverse Actions


Section 3 of CMS 855B defines Final Adverse Actions of the provider

itself, ANY owner (direct or indirect), or managing control of the

provider including supervisory physicians as:

Exclusions, Revocations or Suspensions

Of a license by a State licensing authority

Of Accreditation

From participation in, or any sanction by Federal or State health care program

Any current Medicare payment suspension under any Medicare billing number

Any Medicare revocation of any Medicare/Medicaid billing number.

Convictions of a Federal or State felony or misdemeanor offense within the last 10

years preceding enrollment or revalidation of enrollment in which the individual was

convicted-including guilty pleas such as:

Felony against person

Financial crimes-extortion, embezzlement, tax evasion, insurance fraud

Any felony that placed the Medicare program/beneficiaries at risk

Malpractice results of criminal neglect or misconduct

Felonies resulting in mandatory exclusion under Section 1128(a) of ss Act.

Samples of who is included when reporting

Adverse Actions in Section 5 & 6


Provider/Supplier

Organizational owners of the Provider/Supplier-Direct or Indirect

Direct -Organizations that own the provider

Indirect-Organizations that own the organization that owns the provider

Individual owners of the Provider/Supplier – Direct or Indirect

Direct-Individuals that directly own the provider

Indirect-Individuals that own the company that owns the provider

Authorized & Delegated Official

Supervisory Physicians

All individuals or organizations with management control

CEO, W2 management employees, Management companies, etc

Individuals or organizations with financial control

CFO, Mortgage holders, Loan holders, etc

What are the most common errors when reporting

Final Adverse Actions?

COMMON ERRORS:

Not reporting changes within 30 days of occurrence

Not completing this section and/or other required sections at all or not reporting when actions were: Under a former company name or DBA

Within the last 10 years preceding enrollment or revalidation

Expunged or any appeals are pending

Changed after provider initial enrollment

Under other locations and types (IDTF, lab) with reportable events under the provider name and TIN

Not reporting entities with managing or financial control

Not reporting indirect individual or organizational owner

(individual owner of an organization that owns the provider)

(organizational owner of an organization that owns the provider)

Not attaching a copy of the final adverse legal action.

Deficient research and knowledge of adverse legal actions


Reporting Provider Location Information on

855B


Section 4A: Practice Location Information

As per CMS, Portable X-ray providers will provide the practice location information as the “Base of Operations”

COMMON ERRORS: Using a P.O. Box

Omissions or errors in reporting Suite or room numbers & zip codes (9 digit)

Using a name other than the name on the business signage (DBA vs legal)

Providing non working or unlisted phone numbers

Not reporting changes when they occur or within 30 days of occurrence

Not updating all legal documents-corporate filings, NPPES, state licensure, 588 form, etc.

Section 4B: Where remittance notices/special payments are sent Since payments are made by EFT “Special Payments” address should indicate where all other payment

information should be sent and may only be one of the following:

One of the provider’s practice locations or correspondence address

A P.O. Box

Provider’s billing agent

Chain home office address

COMMON ERRORS:

Submitting an unknown address

Omitting Suite/Room numbers

Not keeping this address current

Reporting Provider Medical Records

Location on 855B


Section 4C: Where do you keep patients’ medical records?

If you store patient records (current or former) at a location other than your physical address or base of operations, you must report the address

If you store patient records at multiple locations-you must report each location

COMMON ERRORS:

Reporting a P.O. Box or drop box

Reporting another provider’s address (ie: referring physician, SNF)

If there is no address reported, Medicare will consider…..that records are stored at the Physical address or base of operations reported in section 4A or 4E

Non-reporting of ALL storage locations

Section 4E: Base of Operations Address for ..Portable Providers

Where personnel are dispatched, where portable equipment is stored and where vehicles are parked when not in use

The provider can only have one base of operations

COMMON ERRORS:

Not reporting at all

Inaccurate reporting and not reporting changes

Reporting Location & Vehicle Information on

855B


Section 4F: Vehicle Information

Complete Only if health care services are rendered inside a vehicle

COMMON ERRORS:

Reporting of vehicles that are used solely to transport medical equipment to

a fixed setting (ie: portable providers)

Omission of reporting by “Mobile” providers (providers rendering service

inside a vehicle)

Section 4G: Geographic Location for Mobile or Portable Suppliers

If you cover an entire State, it is not necessary to report each city/town

If you cover the entire State and the MAC is different for regions within your

state- you must enroll in each MAC

COMMON ERRORS:

Reporting only certain cities or towns, yet providing service in other areas in

the state that are not reported

Not updating when service areas are changed

Reporting Organizational Ownership

interest/Managing control of Provider


Report in Section 5 all organizations that have:

5% or more direct or indirect ownership interest

Organization with a Mortgage or security interest

(financial control)-for purposes of enrollment

Managing control of the provider

Any general partnership interest-regardless of the

percentage

For limited partnership, any interest 10% or greater

Refer to Program Integrity Manual Chapter 15

What is the Difference between Direct & Indirect

Organizational ownership reportable on 855B?


DIRECT ORGANIZATIONAL OWNER(s) EXAMPLE: The supplier is

a PXR company that is wholly owned by Company A. Company A is

considered to be a direct owner of the supplier (the portable X-ray

Company), in that it actually owns the assets of the business.

INDIRECT ORGANIZATIONAL OWNER(s) EXAMPLE: The supplier

is a PXR company that is wholly owned by Company A and

Company B owns Company A – Company B is considered an

INDIRECT OWNER – but an owner – nevertheless of the supplier.

IN OTHER WORDS: A direct owner (there may be more than one) has an

actual ownership interest in the supplier, whereas an indirect owner (there

may be more than one) has an ownership interest in an organization that owns

the supplier.

ALL Organizational owners/managing control must be reported in Section 5

What are examples of Organizational

ownership/managing control and what are the most

common reporting errors?


Examples of organizations reported in Section 5A General, non limited & limited partnerships

5% or more Direct or Indirect ownership

Corporations, LLCs

Financial Control

Banks, financial institutions

investment firms, trusts, trustees, holding companies

Managing Control

Controlling management firms

Medical staffing companies

COMMON ERRORS: Provider lacks knowledge to identify Organizational ownership

Underreports or omits reporting on the initial application or when changes occur

How is Financial Control defined and what are the

most common errors in reporting Financial control on

855B?


Financial Control exists when: An organization (ie: Bank, mortgage lender) or individual is the owner of

whole or part interest in any mortgage, deed of trust, note or other

obligation secured (in whole or in part) by the provider or any of the

property or assets of the provider and the interest is equal to or exceeds

5% of the total property and assets of the provider.

For more information, please refer to Program Integrity Manual Chapter

15.5.5 and 15.5.6

COMMON ERRORS:

Lacks knowledge of the definition of Financial Control

Omits Individual lenders and/or any other secured obligations

Non-reporting or underreporting with initial application or when changes occur.

How is Managing Control defined and what are the

most common errors in reporting managing control?


A managing organization/individual is one that exercises operational and/or managerial control over the provider

Or conducts the day-to-day operations of the provider Management firms, Holding Companies, Staffing companies

Trusts and Trustees, COOs, CFOs, CEOs

The organization/individual need not have an ownership interest in the provider-nevertheless must be identified in section 5A and/or 6A

COMMON ERRORS: Lack of Provider knowledge on how to identify managing control

Not reporting and/or not reporting when changes occur

Reporting Individual Ownership and/or

managing control


Section 6A: List Individuals Only ALL persons with 5% or greater Direct or Indirect ownership interest

Including ALL individual owners of any organizational owner of the provider

IF the provider is a corporation-All officers & directors

At Least ONE individual owner and/or managing employee MUST be reported

All Authorized and delegated officials

All persons with a partnership interest regardless of percentage of ownership

Per Program Integrity Manual-Chp 15- limited partnership of 10% or greater

All managing employees(having operational or managerial control over the supplier), contracted or W2

All Applications must report at least one W2 employee

All persons with 5% or greater Financial Control (mortgage or security interest)

COMMON ERRORS:

Provider lacks the knowledge of how to define individual ownership

Not reporting at least one W2 employee

Does not report or underreports on the initial application or when changes occur

What is the Difference between Direct & Indirect

Individual ownership reportable on 855B?


DIRECT INDIVIDUAL OWNER(s) EXAMPLE: Supplier is 100% owned by one or more individuals All individuals with 5% or greater ownership of the Supplier

All officers and directors of supplier-if supplier is a corporation.

All individuals with partnership interest, regardless of % of ownership

All individuals with 5% or greater Financial Control

INDIRECT INDIVIDUAL OWNER(s) EXAMPLE: Supplier is 100% owned by Company C, which itself is 100% owned by Individual(s) D. Company C is reported IN SECTON 5a as organizational owner of the supplier-and Individual(s) D is reported in Section 6A1 as Indirect owner(s) of the supplier

IN OTHER WORDS: A direct owner (there may be more than one) has

an actual ownership interest in the supplier, whereas an indirect owner (there may be more than one) has an ownership interest in an organization that owns the supplier.

How are Authorized Officials Identified?


Authorized Officials is: An appointed official granted legal authority by the provider to enroll and/or make

enrollment changes or updates for the provider

An official appointed by the provider that will have the authority to bind the provider legally and financially to the program federal regulations.

Must have ownership or controlling interest of the provider as:

President

General partner

Chairman of the board

CFO

CEO

Owner with 5% or more interest in the Provider

Authorized official retains sole authority to make any changes/updates by providing his/her printed name, signature and date of signature as required in Section 15B

Must be reported in Section 6A(individual ownership) and 15

How are Delegated Officials Defined?


Delegated Officials A delegated official is an individual to whom an authorized official listed in section

15 delegates the authority to report changes and updates to the provider’s enrollment

Must have Ownership, controlling interest or be a W-2 managing Employee Managing Employee:

General Manager

Business Manager

Administrator

Operational or Managerial control over operations

You are not required to have a Delegated Official.

The signature of a delegated official shall have the same force as that of an authorized official

Must be reported in Section 6A(individual ownership) and 16

Reporting Adverse Action of Organizational &

Individual ownership/managing control on 855B


Section 5B, Section 6B Final Adverse Legal Action – as

described in Section 3 of 855B

COMMON ERRORS:

Not reporting entities with managing or financial control

Not reporting indirect individual or organizational owner

(individual owner of an organization that owns the provider)

(organizational owner of an organization that owns the provider)

Not reporting actions that occurred under the provider, owner or managing

control former name, or DBA business identity

Not attaching a copy of the final adverse legal action.

Not reporting actions at all and/or when changes occur

Deficient research and knowledge of adverse legal actions

How is a Billing Agency Defined & Where is

that reported?


A billing agency is a company or individual that you contract with to

prepare and submit your claims

If you use a billing agency, you are responsible for the claims

submitted on your behalf

Providers using a billing agency must report that information in

Section 8 of the 855B

COMMON ERRORS:

Agency not reported

Incomplete information reported

Not reporting the Legal business name correctly

Reporting a Contact person in Section 13.

Who is considered a Contact Person?


A contact person is an individual that your MAC will contact if questions arise during the processing of your 855B If you have multiple contact persons listed in section 13,

the first contact person will be notified if any additional information is needed

If No contact person is listed, the provider will be contacted directly if any information is needed

A contact person may be:

An Authorized or Delegated Official

An employee

A consultant or independent management company given surrogacy to complete your application

Completing 855B Section 15 & 16-

Certification statement & Signatures


Section 15 & 16 Additional requirements for Medicare enrollment

Authorized & Delegated officials must read and agree to abide by the

requirements listed in the Certification Statement

Authorized & Delegated officials must verify that they have read & agreed to the

Certification statement by signing:

Paper application: signature must be original and dated

In PECOS: electronic signature must be verified and completed

COMMON ERRORS:

Signature is not dated

Signature is not an original

A newly signed and dated Section 15 was not submitted with requested corrections

to an application currently in process

Penalties for Falsifying information


Section 14-This section explains the penalties for deliberately

falsifying enrollment application to gain or maintain enrollment in the

Medicare program.

Section 1128A(a)(1) of SS Act imposes civil liability on any person, organization,

agency or other entity…presenting a claim that was not provided as claimed and/or

false or fraudulent

Civil monetary penalty of up to $10,000 for each item/service

An assessment of up to 3 times the amount claimed

Exclusion from participation in Medicare and State health care programs

Criminal penalties against individuals

(18 U.S.C.1347) Fine or imprisoned up to 10 years or both

(18 U.S.C 1035) Fine or imprisoned up to 5 years or both

Common Law claims such as “common law fraud” “Money paid by mistake’ and

“unjust enrichment”

Remedies include compensatory & punitive damages, restitution & recovery

Penalties for falsifying information


18 U.S.C 1001 …criminal penalties again individual who willfully

falsifies, conceals or covers up by any trick, scheme or device..

Individual offenders are subject to fines up to $250,000 & imprisonment up

to 5 years

Organizational offenders are subject to fines up to $500,000

Section 1128B(a)(1) of SS Act authorizes criminal penalties for

false statement or representation of a material fact in any

application for benefit or payment

Civil False Claims Act, 31 U.S.C. 3729 imposes civil liability &

penalty of $5000 to $10,000 per violation & 3xs the amount of

damages

Presents false or fraudulent claim for payment or approval

Makes, uses or causes to be made or used a false record or statement to get

false claim paid

Conspires to defraud

Tips for Accurate Enrollment reporting


Maintain a compliance policy –assigning a compliance officer or like position to routinely monitor and report changes-to include revalidations

Utilize PECOS for more efficient and faster updating

Respond to Medicare’s requests for additional information as soon as possible when updating or revalidating

Ensure contact information is correct and up to date

Make sure Company information (legal name, address, ownership, etc) on 855 matches with all reporting documents, such as:

IRS Tax ID (IRS form CP 575)

Legal Business documents (ie bank account, corporation documents, loans, CHOW)

NPI enrollment

CMS 588 EFT authorization agreement

ALL claim forms

All and ANY documents related to provider operations

Ie: Medical reports, correspondence, contracts

ALL signage, marketing materials, etc

Important References


CMS Program Integrity Manual Chapter 15

855B Enrollment & Policy Overview

by Joanne M Lucas, JD, Business Function Lead CMS

MLN Matters SE1617-Timely Reporting of Provider enrollment information changes

MLN Fact sheet-Medicare Enrollment for ……Part B suppliers

ICN 903768 February 2019

Internet Reference:

www.cms.ogv/regulations-and-Guidance/Guidance/Manuals/downloads/pim83c15.pdf

Cms.gov/outreach-and-education/medicare-learning-network-MLN/MLNproducts/downloads/medenroll_physother_factsheet_ICN903768.pdf

http://www.cms.ogv/regulations-and-Guidance/Guidance/Manuals/downloads/pim83c15.pdf





“The Best Preparation for Tomorrow is doing your best today”


portable x-ray medicare enrollment basics jan. 2020 webinar portable … · considered to be a...

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