Reporting to Medicare: How to avoid deactivation, revocation

ByDavid M. Glaser, JD

Imagine that your administrator embezzles from you. You are mad and a victim of the crime. You fire your administrator, turn him in to the police, and he is convicted of a felony. If you fail to report the firing to Medicare, there is a real risk that you will be victimized again as Medicare revokes your billing number due to your failure to update your enrollment form.

Medicare has placed a major emphasis on enrollment forms, referred to as the 855 forms. The various 855 forms are used to enroll in Medicare and to reassign billing rights. Under relatively new rules, the Centers for Medicare & Medicaid Services (CMS) may either deactivate or revoke a billing number if an enrolled physician fails to report certain information. Deactivation is relatively minor, since you can reactivate the number. Nevertheless, if you fail to submit a claim for 12 months under a number, or don’t report a change in information on the form, such as a change in your ownership or control, CMS can revoke your billing number.

Revocation of a billing number is far more serious, since you may not seek re-enrollment for at least 1 year (and potentially up to 3 years). You are required to report things such as, exclusion from the Medicare program of any owner, managing employee or authorized official.

What to report

Some things you should report to Medicare include:

any change in the physicians employed by the group or in administrators whose names appear on a Medicare enrollment form;
any change in ownership of more than 5% of shares (This means that if you add a new shareholder in a group of 19 or fewer physicians, you must notify Medicare.);
any change in the managerial control of the organization;
changes to the board of directors;
any change in practice location (For example, if you start seeing patients at a new site or stop providing services at a site, you must report that to Medicare.);
any final adverse action against your company or a company in which you are an owner (For example, if you have a DME business, and that DME business faces some sanction, you likely need to report it. Revocations or suspensions by an accrediting agency must be reported.);
any final adverse action against one of your shareholder physicians, such as revocation of the physician’s license;
a sanction involved by a state or federal health care program (For example, if Medicaid sanctions you, you must notify Medicare.);
providing services in a new Medicare Administrative Contractor jurisdiction; and
storing your medical records in a new location.

A helpful reminder

This isn’t intended to be a full list of when a notification is required, but a reminder that you need to be alert to common events or major changes in your practice that require you to amend an 855 form.

The odds are that you rarely think about your 855 form. However, it is worth printing one out and reviewing it so you have a sense of the information on it. If any of the information changes, make sure you send in the new information within 30 days. (For some changes you have 90 days but, for many events, the deadline is 30 days.)

If you have any questions about the form, one of my colleagues, Katie Burkhart, would be happy to help sort through them.