A recent encounter with a provider of DMEPOS (not a podiatrist, but a pedorthist) should be a warning shot across the bow to every provider and certainly to every compliance and enrollment officer’s desk. This provider is out up to $250K and possibly subject to False Claims Actions, because they did not properly follow up on the National Provider Enrollment Carrier (NPE).
The specific issue holding up the re-enrollment of a provider with more than 40 years of experience in DMEPOS was not following up with the NPE on their Surety Bond issues. In a post last year this column discussed the other issues with not being fully aware of NPE issues and those repercussions.
These two providers together stand to lose out on a half million dollars in income as well as the drain associated with the costs of procuring the products.
In this current case, the provider thought it was their BOC certification issue and on-site inspection issue which was holding up their re-enrollment. Instead, it was a Surety Bond issue. For those who don’t know about Surety Bonding, this is insurance coverage for the government, in the event the provider declares bankruptcy and is unable to pay back a recoupment or other judgments against the provider. Physician Suppliers are exempt from purchasing Surety Bonds.
Apparently, their bond company notified the enrollment carrier of the provider’s failure to pay the premium and did not notify their client. After two years of threating to disenroll the provider the NPE finally acted and apparently notified them. Medicare continued to pay the provider for newly submitted claims postdate of revocation for almost an additional 18 months. At that time new claims were denied for reasons having to do with the provider’s enrollment status. At this point just about any appeal rights afforded by the Medicare Program Integrity Manual expired. In speaking with the supplier, no employee can provide a notice of Surety Bond discontinuation or the original DMEPOS revocation letter.
Making matters worse, is this supplier rarely if ever receives payment from Medicare, because the services provided are mostly excluded from Medicare coverage. Their enrollment in DMEPOS is strictly so they can submit claims to rejected for adjudication, to facilitate reimbursement by the secondary carrier (private or public). A further blow is that some claims would have been paid by their state Medicaid program. However, contingent on Medicaid participation is continued enrollment as a Medicare DMEPOS provider.
What are the lessons learned from this scenario?
There are ten lessons learned which every supplier should take seriously:
- Provider enrollment has become extremely complex, and reenrollment takes planning in order to avoid it becoming a threat to your future financial stability.
- Each provider needs their own provider manual. The manual should delineate which employee(s) is/are responsible for provider integrity and enrollment.
- The employee opening the mail should be properly instructed on mail which takes priority and who that mail should be routed to. That employee should also be responsible and documenting their follow up with the employee they initially referred the matter to. This to ensure those materials have been read and acted upon.
- All correspondence from the National Provider Enrollment (NPE) Carrier should be logged in and marked for comment, editing and completion by the responsible employee in accordance with any deadlines noted from the NPE.
- On the third year of every provider’s DMEPOS enrollment, the employees opening the mail should be regularly instructed to watch for the yellow envelope from the NPE.
- During the final year of your triennial enrollment, the designated responsible employee and owner of the DMEPOS company should be tracking their enrollment status on a regular basis. Simply input your NPI number into the revalidation list. This will tell you when your are due for revalidation.
- This can be done free of charge at the Medicare Revalidation list, which can be found at: https://data.cms.gov/tools/medicare-revalidation-list
- Know what CMS expects of your specific specialty and be sure all those essentials are included in the PECOS or 855S paper application on your initial revalidation application.
- Be sure your Surety Bonding, if required by Supplier Standard 26 and your Comprehensive Liability (as required for all suppliers as per Standard number 10) is up-to-date and in accordance with the standards.
- Many suppliers have faced serious financial difficulties due to revalidation issue. Every provider should hire an expert with extensive knowledge in the enrollment process. The Medicare Integrity Manual Chapter 10 extensively documents the many nuances of provider enrollment, is well over 900 pages and regularly changes. Suppliers and their billers only submit these applications once every three years. Since the atmosphere seems to slant to supplier disenrollment, the wise supplier will hire an expert to handle the intricacies of their supplier enrollment.
