Episode 6 - Medicare Enrollment Processes and Strategies

Please see below for a full transcript of this episode:

Health systems are consolidating and expanding their footprint at record speed. This two-part series first examined the provider-based status requirements and related hot topics, and this second, final episode in the series examines Medicare provider enrollment hot topics and strategies for maximizing reimbursement deficiencies.

Welcome to Redefining Health Law, brought to you by the law firm of Parker, Hudson, Rainer and Dobbs, LLP, a boutique law firm with offices in Atlanta, Chicago, and Tallahassee. Your host for this podcast is Tara Ravi, a healthcare partner with prior work experience in both clinical research and patient care delivery.

She is an adjunct professor at the Emory School of Law where she teaches corporate health law. Tara leverages her past work experience in the healthcare industry to advise healthcare organizations facing growth related challenges. Although Tara is a partner in the law firm of Parker Hudson, the views expressed in this podcast are Tara's personal views and not the views of the firm or any of the firm's clients and are not intended to be legal advice. We hope you enjoy this podcast.

Hi there and welcome back to Redefining Health Law. Today we finish out the second part of our provider-based series discussing the ever evolving and to some extent diminishing issue of hospital provider-based status. In an effort to keep these podcast episodes short and to the point, today's discussion addresses provider based hot topics at a high level.

Always feel free to reach out to me directly at redefininghealthlaw@phrd.com if you have any specific questions you would like to address. Okay, so let's get started. Our last episode discussed the relevance of provider-based requirements for expanding and consolidating health systems. Today, we discuss the Medicare enrollment process and strategies for creating alignment across internal departments to maximize enrollment efficiencies.

Okay, so a summary of Medicare enrollment. Medicare enrollment for a health system seeking provider-based status would occur on the 855. The 855 can be a paper application or a web-based enrollment. And nobody would really use the paper application unless they were forced to, because the web based is so much more efficient. Except, given the recent issues we've been having, many systems are forced to submit paper applications because of backups and clogged PECOS enrollments. So, what's PECOS? Provider Enrollment Chain and Organization System.

That is the shorthand PECOS or the Online System for Medicare Enrollment. Just a small background. Medicare enrollment it's typically not given an entire department by healthcare system. There is some private Information that's involved in the Medicare enrollment like social security numbers to the CFOs, the CEOs, birthdates, personal information. It's one highly trusted individual and then certain individuals in their department that would cover Medicare enrollment updates. That position could be housed in compliance, it could be housed in finance, it could be housed in reimbursement, it could have its own group. And knowing how hospital system departments are organized is also helpful in creating enrollment strategies to maximize reimbursement.

Okay, so that's the background of who does the enrollment. What is the enrollment? Like I said, it's an online system and you have to enter in information about the health system, about the owners. There's about, if it's for a hospital, maybe 60 or 70 pages on the paper application of information that's collected.

And this episode is not going to focus on that because I'm assuming for the most part, my listeners to this episode are somewhat advanced because we're going to be talking about hot topics.

In 2017, CMS outlined billing requirements for outpatient providers who submit claims for services rendered at hospital outpatient provider-based departments. Specifically in that guidance, CMS highlighted that the addresses of these outpatient departments must be very specific, must be entirely accurate. For many years after that, the edits were never put in place. CMS did say COVID was a part of that, but somewhere around the end of 2023, CMS said, we're going to get to it and start looking at all the addresses on your provider-based department.

Now, like I said in the last episode, keeping track of some of these outpatient departments when you have a large hospital system or a system that's consolidating and expanding is somewhat difficult. And granted, you want to make sure you're compliant and you're not billing for services at a location that doesn't exist, but looking at very technical addresses can change.

A suite number can change, a zip code can change, a comma can change, the name of a street can change. So, some of these addresses, let's say you've got 100 or 50 outpatient sites, may not be entirely accurate. And this is what CMS was beginning to start editing or reviewing. It was great that at the end of last year, CMS gave everyone a heads up via some publications.

But we really didn't know what that was going to look like. And what it started looking like was claims getting denied because the address didn't match up. And so that forced a domino effect internally among many of these systems, because five or six different internal groups would have to talk to each other to correct that.

And what is the correction process? I want to talk about how inefficient and difficult the correction process is, and then we can get to how to align your interdepartments so that submitting any changes through that correction process can happen efficiently or can proactively be avoided. So, what is the correction process?

Typically, someone in your reimbursement department is going to get a claims denial for services provided at an outpatient provider-based department. And the claims denial will have a specific code that describes what the problem is, what the edit is and there's a specific code that will say, this location is incorrectly stated, or your address is wrong, or maybe you're billing it as a grandfathered, remember we discussed that date in the last episode, site, and it's not supposed to be a grandfathered. And these are all the pieces of information that are collected in the PECOS for a particular site. So once reimbursement gets the denial, we’ll look at what the denial is, and if it has something to do with one of the address nits I described or the accepted grandfathered status, then the denial goes into, let's say, a denial process, which is considered like an administrative denial, just fix that little aspect on the claim and send it back.

But maybe you can't fix the address because your enrollment hasn't been updated, or maybe you can't fix the grandfathered status because actually it is grandfathered and you don't want to take a claim denial for something that isn't actually true. We can get into that concept on a different episode, but now just let's just talk about fixing the enrollment and addresses.

So, your reimbursement department got a denial saying that there's an issue with how this outpatient location is enrolled in the address. Great. Now we need to find out how to fix it. And there's two ways of fixing it you need to get the right address and give it to your, whoever is tasked with updating the enrollment.

Now, from what we've heard, the right address is what USPS is using and this has created so many difficulties for our clients because the word road maybe is spelled out in your enrollment, but USPS uses RD or the word suite, or there's a period or a comma that is in your enrollment or shouldn't be in your enrollment. So, you can see how this is a headache for everyone, because that little period or that abbreviation is causing millions of dollars of claims to get rejected on this address denial. And while CMS says they gave us fair warning in 2017, we certainly didn't think that the address nits would be like this one word capitalized in a place where CMS just doesn't want it capitalized, or at least says that the USPS doesn't want it capitalized.

Okay. I launched into a little bit of a long explanation on that, but it's been very frustrating for lots of our clients. So, what do we do to fix it? It seems like we can just go into our PECO system, fix the address very quickly, hit send and call it a day. Well, that would be awesome, except that's not really how it's working right now.

We can go and talk to the enrollment person, the enrollment person goes into the system, fixes it, and then it's getting stuck in a total log jam. And what's that log jam? In our state, when it gets fixed in the, or at least when it gets entered into the PECO system, PECOS then reaches out to the local contractor for your jurisdiction, and then the local contractor specifically for addresses is reaching out to your state for us at State Licensure Department, and they have to corroborate the state that this address really exists, even though all you fixed was an abbreviation or maybe a capital letter, and that's sitting in a pile On licensure's department, which is creating a giant backlog. And then that department gets some paper over to the local contractor, gets it back over to CMS, who gets it back over to the contractor, and that's how your address got fixed, except let's say you're, like I said, a consolidated or like growing healthcare system, and you're opening up outpatient sites by the tens or the dozens.

Maybe some of them haven't been cleaned up from a long time ago. Maybe they've been in place for almost 10 years or more, and now you had to add a suite number because the addresses have changed, or the zip codes have changed. So, there's the issue of fixing an immediate problem that you're seeing when claims are getting denied. But then there's also the issue of, as a general matter, going through your enrollment and cleaning up all of these issues and the first thing you'd want to do, just based on what I said, is because CMS told us that we're using our USPS addresses, is you'd go over your enrollment, all over your outpatient sites, cross reference all of the USPS addresses, and see where that needs to be fixed.

Then you need to go and update that in your CMS enrollment, but it creates the backlog with licensure, with the local contractor, with CMS that I just described. So, you kind of don't want to piecemeal it and just fix the claims denial addresses. We're going to discuss like a good process of going through your entire outpatient department addresses and outpatient department information so that you can coordinate across the department.

And what are the departments I'm talking about? Well, in the first episode we discussed there's this concept that involves marketing all of the signage and how you're going to market sites on your website and how you're going to actual market sites that are providing services. So, let's just call that marketing, then we've got compliance, then we've got reimbursement. We've got finance that enters into some of these arrangements I discussed provider-based arrangements, management arrangements, joint ventures. And then we've got our enrollment department. Let's just assume that's a separate department.

How do we coordinate among all of these departments, all of the outpatient sites that are growing? I mean, they're literally growing by the month. You could be adding one or two every month, just given how active a system is. The best way to start is to create some good process documents, and, compliance is always going to be overseeing your outpatient departments because they need to maintain provider based compliance, and that should be, I mean, maybe it's an annual check, maybe it's a biannual check, maybe it's a monthly check, and it's coordinating with, if you've got multiple hospitals, those specific heads to make sure that the addresses are accurate, and the locations where we think those services are being provided are, in fact, being provided at those locations. Maybe something's moved, maybe a building got shut down because the air conditioning broke and we're now providing it somewhere else. Those are the cleanup items and then taking all of that information and setting probably weekly or monthly calls across the groups that I just described, which is very time consuming, but if you have one designee from each of those groups and everybody can coordinate the flow.

So, we've just said compliance has done a review, number one, number two, coordinate that with your reimbursement group who's actually getting these denials. Maybe they've gotten some more denials from some other locations tack that into our information, and when I say information, ideally I'm imagining like a very beautiful spreadsheet where we're tracking every single outpatient site.

We can highlight hot ticket items where we know we have immediate reimbursement issues that are causing huge financial delays or like large amounts have that cross referenced with finance and then finally with marketing because we need to make sure that all of those public awareness requirements, the signage are being complied with as well.

So, the short of this episode is the process itself to fix a comma can now take maybe weeks or months, some of these backlogs can take up to six, seven, almost a year. If you don't track it properly and it clogs up your system PECOS, meaning any other change you need to make, not just to your outpatient locations, but maybe you need to update a board member's address, maybe you need to update that you're going to be storing medical records somewhere else. You can't make that update because it's frozen, and now you have to go back to the paper application, which we had stopped using for a long time, but because these backlogs are occurring now, we're submitting paper applications and you could have multiple updates freezing up your system if you don't have organized alignment across all these interdepartments that I just described, having these piecemeal submissions occur doesn't help anybody in the long run and can create reimbursement inefficiencies because we don't know what has been updated we don't know what we're compliant with. Compliance has to oversee all of these as well because it could kick your provider base status out, and so that's why it's very important now that CMS is implemented these edits, but also has implemented this backlog to stay on top of it as best you can and create internal organization. And the more organized you are internally, the more you can kind of hold the hand of the relevant government authorities to let them know proactively when a change is going to occur so that maybe it can happen a little bit more efficiently on their end as well. Alright, so that's my summary on enrollment hot topics and how to create internal alignments to maximize provider-based enrollment efficiencies.

We hope to see you again next time. We're now getting towards the end of the year, and we're looking forward to some more episodes on different topics. Thanks again for listening to Redefining Health Law. If you haven't already, I invite you to subscribe on your favorite podcast player so you won't miss an episode. And of course, please, please, if you have any topics you'd like to hear discussed, if you'd like to come on and be a guest, that would be great too. Please don't hesitate to email us at redefininghealthlaw@phrd.com. Again, that's redefininghealthlaw@phrd.com.

We'd love to hear from you. Thank you for listening, and until next time, I'm Tara Ravi.