The Path to Provider Enrollment with Medicare
Provider enrollment in Medicare is a critical process that ensures health care providers are authorized to offer services to Medicare beneficiaries and receive reimbursement from Medicare.
Whether you’re a physician, a non-physician practitioner, or a facility provider, understanding the enrollment process is essential for maintaining compliance and optimizing revenue flow. Providers generally must coordinate their Medicare enrollment process with state licensing, Medicaid enrollment, and commercial payer contracting.
Staying proactive and informed about updates to Medicare’s policies is key to ongoing success in navigating this vital area of health care administration.
What Is Provider Enrollment?
Provider enrollment is the process of registering with Medicare to obtain billing privileges. This allows providers to submit claims and receive payment for services rendered to Medicare beneficiaries. The process involves verifying credentials, meeting eligibility requirements, and submitting necessary documentation to the Centers for Medicare & Medicaid Services (CMS). The federal regulation 42 CFR Part 424, Subpart P outlines the requirements for Medicare enrollment, including the obligation to furnish accurate and complete information and maintain enrollment updates.
The enrollment process and requirements differ based on the type of provider or supplier and the services you offer.
- Providers, such as physicians and non-physician practitioners, generally use CMS-855I for individual enrollment.
- Group practices or clinics use CMS-855B to enroll.
- Institutional providers, such as hospitals or skilled nursing facilities (SNFs), use CMS-855A. Medicare has issued updated guidance requiring SNFs to provide more comprehensive disclosures regarding their ownership and management structures. These revisions became effective on October 1, 2024.
- Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers must complete CMS-855S.
The Medicare enrollment process also varies depending on the specific purpose of the enrollment activity.
Initial Enrollment
Providers or suppliers seeking to enroll in Medicare for the first time to obtain billing privileges go through an initial enrollment. Depending on the provider type, Medicare categorizes applicants as limited, moderate, or high risk, which determines the extent of additional requirements like site visits or fingerprint-based background checks.
Revalidation
Current providers or suppliers undergo periodic reviews required by Medicare to ensure all enrollment information remains accurate and up to date. This process usually occurs every five years, but high-risk provider types (e.g., home health agencies, DMEPOS suppliers) may need to revalidate every three years. While you should keep track of your revalidation due date, your Medicare Administrative Contractor (MAC) will send you a notice in advance.
Re-Enrollment
Providers or suppliers whose enrollment was previously revoked or voluntarily terminated are required to reapply to regain billing privileges. While usually similar to initial enrollment, this process involves additional scrutiny and may involve a waiting period or additional penalties, depending on the circumstances of the prior revocation.
Updates
Providers are required to report any changes, including address, ownership, legal business name, tax identification number (TIN), and the addition or removal of practice locations.
Failure to update information or complete revalidation may result in claim denials, payment delays, penalties or lead to the deactivation of Medicare billing privileges. Providers who do not complete the required revalidation process within 60 days of receiving a revalidation letter from their MAC risk having their Medicare billing privileges deactivated.
Complexities Involving Change in Ownership (CHOW)
A CHOW is a complex, high-risk process requiring careful planning, attention to regulatory compliance, and financial due diligence to ensure a smooth transition without revenue loss or compliance violations.
CHOWs must be reported to CMS within 30 days using the appropriate CMS enrollment forms per 42 CFR § 424.516. Depending upon the provider type, approval may also be required from state licensing agencies, Medicaid, and commercial payers.
The new owner can accept assignment of the existing Medicare Provider Agreement, inheriting conditions and liabilities, including potential overpayments, audits, and penalties. Alternatively, the new entity can terminate the agreement and re-enroll, which may result in temporary payment disruptions and may have other reimbursement impacts.
Given the complexities of regulatory compliance, legal requirements, and reimbursement risks, engaging legal, financial, and operational experts is essential for a smooth, successful transition.
Institutional Provider Enrollment
Institutional providers, such as hospitals, skilled nursing facilities, home health agencies, outpatient clinics, ambulatory surgical centers, community mental health centers, and federally qualified health centers, have specific requirements for Medicare enrollment. The process includes additional steps to ensure compliance with federal regulations and to confirm that the facility meets Medicare’s operational and quality standards.
Eligibility and Application
Institutional providers must complete the CMS-855A form or use Provider Enrollment, Chain, and Ownership System (PECOS) to apply.
The application undergoes a detailed, multistep review process. MACs handle the initial stages, which include intake, screening, verification, fingerprinting (if required), and referral to the State Agency (SA) or the Accrediting Organization (AO) for next step of review. This first step of the process takes 30-65 days.
While CMS Regional Offices (RO) are still involved in certain aspects of provider enrollment, their role has evolved. Their direct involvement in the day-to-day enrollment process has decreased in favor of MACs handling the bulk of administrative tasks. CMS regional offices may still step in if there are complex issues or disputes that MACs cannot resolve, or in cases that require additional oversight or guidance at the regional level.
Certification and Accreditation
The appropriate SA or AO undertakes the next level of review including need for certification survey. Certification ensures compliance with Medicare Conditions of Participation (CoPs), which include patient safety, care quality, and operational standards. This step varies based on the type of application. The process for initial enrollment differs from that for changes in ownership or updates to existing information.
Site Inspection
Medicare may require an on-site survey to verify that the facility meets the necessary standards. If a site visit is required, the process typically takes up to 45 days. If no site visit is needed, the process may take 10 days.
Enrollment Approval
After meeting all requirements and completing the application process, institutional providers receive a CMS Certification Number (CCN) and effective date, allowing them to bill Medicare for services provided to beneficiaries.
Common Pitfalls in Provider Enrollment
Avoiding these pitfalls requires careful attention to detail, proactive communication with Medicare review, certification, and enforcement entities, as well as a solid understanding of Medicare's enrollment rules and timelines.
Incomplete or Incorrect Applications
Missing required fields or documents such as licenses, National Provider Identifiers (NPIs), or tax IDs, can slow the process, as can providing inaccurate or outdated information, such as old practice addresses or incorrect ownership details.
Failing to Respond Promptly to Additional Requests
MACs may request additional information or clarification. Delayed responses can result in application rejection.
Not Understanding the Specific Enrollment Requirements
Navigating Medicare’s rules and requirements can be daunting, especially for new providers. Providers may overlook the distinct requirements for their provider type, such as individual practitioners vs. group practices vs. institutional providers.
While the general framework for Medicare provider enrollment is governed by federal guidelines, individual SAs may have different procedures for processing provider enrollment applications, particularly regarding timelines, specific documentation, and state-level requirements
Neglecting Revalidation Requirements
Providers must periodically revalidate their enrollment to maintain billing privileges. Missing deadlines can lead to deactivation.
Ignoring the Need for Updates
Failure to promptly report changes such as practice locations, ownership, or tax identification numbers can result in noncompliance.
Using Paper Forms Instead of PECOS
Paper applications are prone to manual errors and take longer to process compared to PECOS.
Lack of Awareness About On-Site Inspections
Institutional providers may fail to prepare for unannounced site visits, which can delay or jeopardize approval.
Mismanaging Medicare Rejections or Revocations
Failing to address revocation notices or denial letters promptly can make the re-enrollment process lengthy and challenging.
Underestimating the Complexity
Providers may underestimate the time and effort required to gather documentation, verify credentials, and navigate CMS requirements.
Overlooking State-Specific Regulations
Enrollment often requires compliance with both federal Medicare rules and state-specific regulations, which can vary.
We’re Here to Help
For additional support in navigating the complexities of enrollment, please contact your Moss Adams professional.