60K lost due to non complaince with reenrollment
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It’s truly amazing how the real world of DME enrollment tragedies continues, this despite the increased warnings posted in many published articles on this subject. This past week a former client advised me that he had not been paid for several months because his enrollment was never revalidated and he is potentially now out more than $50,000 in outstanding DME claims plus the cost of the DME.
The physician was told that there is no magic wand to reverse this. It appears that the one employee who oversaw processing credentialing was no longer working in the practice. The doctor was hoping I could intervene and resolve this. There was a day where this may have been somewhat easier to fix, but today that is no longer the case.
What vulnerabilities does your practice have in the same scenario? Does your practice possess adequate backup workflows to handle this in case the credentialing employee either retires, quits or is terminated?
For DME credentialing, the revalidation process for your PTAN is strictly enforced. You have a struct window to respond to an initial request. Once they have your application, they will send out an inspector and then process the application only if inspector’s report is favorable. If there are any further deficiencies, during the application process, you must appeal those immediately and you will be granted a “stay of disenrollment” until you provide the required information.
If you fail the inspection, you must appeal this decision immediately, again to get a “stay of disenrollment”. During this “stay” time, you cannot submit claims for payment, but you will not be disenrolled. If you fail to respond to any “Additional Documentation Requests (ADR) then you may be terminated and disenrolled from Medicare for up to two years once your deadline for your PTAN expiration has passed. CMS is postulating whether to extend disenrollments for up to a decade. Your PTAN may expire and your PTAN ma be subject to a Stay of Disenrollment so long as you respond to the ADR and until your application is approved.
But it is important to remember, that once your PTAN is under “Stay” you will not be paid for any claims which took place during that time period.
In the scenario presented, it is apparent that no one working at the practice understood that the DME enrollment revalidation was in process. Their first hint was claims not being paid and being told that they were terminated from Medicare. Why? Because Medicare only sends out one notice. If it is lost in the mail or in your office, it’s too bad. If you have a terminated/retired or quit employee who was supposed to handle this, that’s also too bad. Medicare assumes you know when you are up for renewal and their reminders are “courtesies”
There are several lessons to be learned here.
- There needs to be a backup process in place in case of credentialing employee turnover. Someone must take charge (e.g., the physician practice manager or practice owner themselves) and sort through all the revalidation files.
- Have regular staff meetings where credentialing is discussed. When you are within six months of re-credentialing start the process of hiring an outside trusted credentialing service, especially for DME. The fees charged pale in comparison to lost revenue for one or more years.
- Don’t rely on the USPS to deliver your revalidation notices. The NPE refuses to back down from relying only on mailing notices. They claim practices and individuals change email addresses and key employee all too frequently. Since you are legally obligated to notify the NPE of a change of address, their only legal obligation of revalidation, is to notify you via USPS. Because mail gets lost, it is extremely important to keep track of when your revalidation is due as opposed to relying on their notification.
- Develop an Excel table of all credential issues and make it available to numerous employees. This should contain all relevant provider ID numbers, insurance name and the date the provider number was issued and when it is to be revalidated. The table should also include the specific information the third-party payer requires to make a favorable decision.
- For regular Local Fee for Service Medicare the revalidation period is every five years and for DME it is three years from the date of the last revalidation. Other carriers have different requirements. A copy of the affirmation of validation should be kept in the same folder.
One user friendly key resource every practice should keep handy to determine when their DME revalidation is up: https://data.cms.gov/tools/medicare-revalidation-list
DME fraud is real and the response to this from CMS and the Federal Government has been very clear. Strict enforcement of enrolment and revalidation guidelines.
DME is a real positive source of revenue for your practice. You must do everything in your power to protect your ability to provide patients with medically necessary care. Don’t rely on one individual in your practice to jeopardize your DME enrollment. Please ensure you have back-up workflows which allow someone to easily step in should there be a change in key personnel in your practice.
- There needs to be a backup process in place in case of credentialing employee turnover. Someone must take charge (e.g., the physician practice manager or practice owner themselves) and sort through all the revalidation files.
