Avoid Common Rejections And Errors With 855 Form Submissions

The Centers for Medicare & Medicaid Services (CMS) are taking steps to improve oversight of the Medicare program. They've recently updated enrollment regulations and policies, aiming for greater transparency and accountability. Key changes include updates to Medicare provider and supplier enrollment regulations and Form CMS-855A, which hadn't been updated for twelve years. These updates reflect CMS's commitment to ensuring program integrity, especially as the healthcare landscape adjusts post-COVID-19. Notably, CMS is focusing on disclosing ownership and control interests for certain providers, such as skilled nursing facilities. This effort highlights CMS's dedication to keeping the public informed and maintaining high standards of care.

Below, we have summarized the crucial changes in Medicaid managed care enrollments in 2024 that healthcare providers and professionals need to be aware of.

CMS Medicare Revocation Update

The Medicare program ensures that healthcare providers and suppliers meet certain standards to maintain quality care and accountability. However, enrollment in Medicare may be revoked for various reasons outlined in the regulations.

According to 42 C.F.R. § 424.535(a), the Centers for Medicare & Medicaid Services (CMS) have defined the grounds for revocation of enrollment in the Medicare program. CMS may revoke the enrollment of a provider or supplier for reasons ranging from noncompliance to violation of enrollment requirements.

When a revocation occurs, the supplier's billing privileges are terminated, and they face a re-enrollment bar, which prohibits them from re-enrolling in the Medicare program for a specified period. The duration of this re-enrollment bar depends on the severity of the basis for revocation, ranging from one to ten years.

Previously, most revocations fell under noncompliance, allowing providers to submit a Corrective Action Plan (CAP) to resolve the issues. However, recent changes have reclassified revocation reasons, adding violation of DMEPOS (Durable Medical Equipment, Prosthetics, Orthotics, and Supplies) Supplier Standards as a distinct category.

Under this new classification, if a supplier violates DMEPOS Supplier Standards, the only recourse is to submit a Reconsideration, providing evidence to challenge the initial determination. This change eliminates the option of submitting a CAP for resolution.

For instance, if a supplier fails to update their enrollment file for changes such as surety bond coverage, licensure, or insurance within the required timeframe, and the violation is discovered during an audit, they would face revocation under the new classification.

The impact of these changes on the healthcare industry has raised concerns among stakeholders. The van Halem Group, representing DME MAC and NPE Advisory Councils, has communicated these concerns to CMS. While CMS has acknowledged the concerns, no timeline has been provided for potential changes in guidance to mitigate the severity of revocations.

CMS Update: Stay of Enrollment

CMS has introduced a new procedure called the Stay of Enrollment, which aims to lessen the impact on providers and suppliers compared to the deactivation or revocation of Medicare enrollment. This pause in enrollment, termed a "stay," serves as an interim status.

According to a recent CMS MLN Matters article (MM13449), a stay of enrollment involves two steps: first, the provider must be non-compliant with at least one Medicare enrollment requirement, and second, this non-compliance must be remediable by submitting specific CMS forms, such as the 855 enrollment application or 588 EFT authorization agreement. If the issue cannot be resolved through form submission, a stay cannot be imposed. Examples of scenarios warranting a stay include failure to report address changes, non-response to revalidation requests, or neglect to report management changes.

During a stay, providers remain enrolled in Medicare, but claims submitted for services during this period will be rejected. The stay typically lasts up to 60 days unless compliance is resumed earlier. It's not considered an adverse legal action, and multiple stays may be imposed for separate instances of non-compliance.

Eligible providers are notified of a stay via hard-copy mail, email, and fax by their Medicare Administrative Contractor (MAC). They can file a rebuttal to challenge the stay, demonstrating compliance with enrollment requirements. The MACs coordinate and communicate with each other during the stay period, ensuring consistent handling of the situation.

855 Form Submissions Updates

This is a form for certain healthcare organizations that want to join the Medicare program or update their information. It's called the CMS-855A form. You can fill it out online or on paper through a system called PECOS. It’s crucial to use the latest version of the form to find the latest information and download the form from the CMS website.

If you belong to one of these healthcare organizations listed here, you need to fill out this form: Community Mental Health Center, Comprehensive Outpatient Rehabilitation Facility, Critical Access Hospital, End-Stage Renal Disease Facility, Federally Qualified Health Center, Home Health Agency, Hospice, Hospital, Indian Health Services Facility, Opioid Treatment Program, Organ Procurement Organization, Outpatient Physical Therapy/Occupational Therapy/Speech Pathology Services, Religious Non-Medical Health Care Institution, Rural Emergency Hospital, Rural Health Clinic, Skilled Nursing Facility.

If your organization isn't listed, you should contact your Medicare Administrative Contractor (MAC) before filling out this form.

• If your organization is joining the Medicare program for the first time with a particular Medicare Administrative Contractor (MAC) using a specific tax identification number.
• If you're already enrolled in Medicare but have received a new Tax Identification Number, you'll need to submit a new application to update your information.
• If you're already enrolled in Medicare and need to expand into a new area covered by a different MAC, such as opening a new practice location, you'll need to enrol with that MAC.
• If you're required to revalidate your Medicare enrollment, you'll be notified by your MAC when it's time to update your information. Don't send in a revalidation application until your MAC contacts you.
• If you were previously enrolled in Medicare but need to start billing again, you'll need to meet all current requirements for your supplier type before you can reactivate your billing number.
• If you're already enrolled in Medicare but need to make changes to your enrollment information, such as adding or changing a practice location, make sure to report these changes within the specified timeframes outlined in the regulations.

Navigating Medicare enrollment procedures can be complex, but staying informed and proactive about Medicaid managed care enrollments in 2024 can help avoid common rejections and errors when submitting Form 855. First and foremost, healthcare providers and professionals should regularly update themselves on any changes to Medicare regulations and enrollment requirements through official CMS channels. Timely reporting of any updates or changes to enrollment information, such as address modifications or shifts in management, is essential to maintain compliance and prevent potential issues.

Understanding the reasons for enrollment revocation, particularly recent changes regarding violations of DMEPOS Supplier Standards is crucial for taking appropriate action if needed. Additionally, maintaining open communication with the Medicare Administrative Contractor (MAC) ensures awareness of revalidation requirements and any notifications regarding stays of enrollment. By following these steps diligently, providers can streamline the submission process, mitigate errors, and ensure uninterrupted participation in the Medicare program.