Medicare File Hygiene

For any medical services provider, the ability to bill Medicare is one of the foremost financial considerations in funding operations.  Many of our clients ultimately bill anywhere from 40-70% of their transports to a Medicare plan.  After the original enrollment is completed, the Medicare application process often becomes a distant, slightly painful memory, and maintaining correct information in your provider file is low on the priority list as long as the payments keep coming in.  However, in this era of increasing scrutiny for fraudulent billing, including site visits to provider’s address of record by Medicare contractors, we are recommending that our clients develop a process to review the information contained in their Medicare provider file to ensure that any changes get properly reported to Medicare.   The expectation by Medicare is contained in the quote below, which is taken directly off of a recent award letter to a new provider.

...“Finally, you are required by regulations found at 42 CFR §424.520 to submit updates and changes to your enrollment information in accordance with specified timeframes. Reportable changes include, but are not limited to changes in: (1) legal business name (LBN)/tax identification number (TIN), (2) practice location, (3) ownership, (4) authorized/delegated officials, (5) changes in payment information such as changes in electronic funds transfer and (6) final adverse legal actions, including felony convictions, license suspensions or revocation of a health care license, an exclusion or debarment from participation in Federal or State health care program, or a Medicare revocation by a different Medicare contractor.

Providers and suppliers may enroll or make changes to their existing enrollment in the Medicare program using the Internet-based Provider Enrollment, Chain and Organization System (PECOS). To apply via the Internet-based PECOS or to download the CMS-855 enrollment applications, go to For help with future enrollments, please visit our Provider Interactive Enrollment interview at pie/index.html.”

These requirements are not new, but are receiving increased attention, and punishments for those who are found to be non-compliant could include being barred from billing Medicare, which would be devastating to any provider.  In addition to increased scrutiny, Medicare has recently instituted a $505 fee for the processing of provider enrollment applications.  This will primarily affect new providers, but providers whose files have not had updates on a regular basis may be identified as needing “revalidation” to bring the file up to date which also carries the $505 fee.

Systems Design is always willing to assist clients with their Medicare updates, since we are conversant with the forms and the process, but we ask that our clients take the initiative to inform us when any of the types of changes mentioned above are in process, and also for smaller changes like the acquisition or retirement of patient transport vehicles.   Our suggestion is that your Medicare file review be part of the data gathering process that goes on when you renew your EMS license with the State.  At that point you are already looking at data about your vehicles and personnel and would be able to note any differences since the last renewal and do the necessary paperwork on the spot.    Of course, the retirement of an Authorized Official or a move to a new practice address should be reported to Medicare immediately, but we’ve found that vehicle changes are the most common update needed by ambulance providers, but the least often done.   Also, since Medicare requires all providers to accept their payments via EFT, remember that changes to your bank routing and account numbers, either by your own choice, or due to bank mergers/acquisitions should be sent to Medicare for update as soon as possible so that there is no drop in your cash flow while the update is in process.   A regular habit of updates to your Medicare file will insure that your contractual relationship with this Federal entity will remain in good standing.

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