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Medicare Provider Enrollment - part 2 Print E-mail
Written by Benjamin L. Frosch   
Friday, 16 May 2014 16:07

                            Medicare Q & A

Q:  For new physicians, are there certain attachments that should be submitted with their CMS 855I?

Specialty Group Administrator
A:  In addition to submitting the CMS 855I, you should include copies of their medical school diploma, medical license, and board certification if applicable. It is also a good idea to submit a copy of a passport or driver's license to confirm their signature. Also include the CMS 855R reassigning their benefits to your group.
Q:  During the revalidation process, if an error or information is missing on the physician's CMS 855I application, will their billing privileges be de-activated?
-Office Manager
Internal Medicine
Miami FL

A:  They would not be deactivated. They would receive a letter from Medicare Provider Enrollment requesting that additional information should be sent or that the application requires a correction. They are usually very specific in their correspondence and they will give you thirty days to submit the requested information. If you fail to respond, you will be deactivated.

  We are a busy practice in Miami and are adding 2 new physicians in July. A colleague shared with me that he is waiting months for approval because he is waiting to be "interviewed" by Medicare prior to being issued billing privileges. Is this something new and how do we expedite the process?

-Managing Partner
Cardiology Group
Miami, FL

A:  I would not call it an "interview". It is part of the enrollment process in most of Florida to stop fraud. It should only take a few minutes for Medicare to speak to the physician and confirm his/her identity and his/her reassignment to your group. This is done by Medicare in person, where they go to the practice location to see the physician, or by phone. 

I suggest that the new physician's best contact phone number be put in Section 2 of their CMS 855I. Insert the office number or the physician's cell number. You should alert the front desk staff and your new physician to expect to be contacted by Medicare Provider Enrollment. If the physician is not available by phone, please have him return the contact call from Medicare as soon as possible or the application will be delayed.
Mr. Frosch is the President of Frosch Medical Consultants in Plantation, FL.  Got a Question for Ben?  Click Ask Ben

Last Updated on Wednesday, 02 July 2014 09:17
Medicare Provider Enrollment Print E-mail
Written by Benjamin L. Frosch   
Wednesday, 14 May 2014 11:58

Medicare Q & A

Q:  I understand that we can now apply online for Medicare enrollment. If we decide to apply using the electronic enrollment option, will we be able to bill retroactive beyond the thirty days?


Specialty Group Practice

Naples, FL

A:  The same 30-day rule would apply. The date of filing for internet-based Provider Enrollment, Chain and Ownership System (PECOS) applications for physicians, non-physicians, and organizations is the date the contractor received an electronic version of the enrollment application, a signed certification statement and all the required attachments that were all processed to completion.

Q:  Are there any other "time limit" changes pertaining to Medicare provider Enrollment for other providers?


Specialty Group Practice

Miami, FL

A:  There are "time limits" that address other Medicare provider issues. Physicians, Physician-Assistants, Nurse-Practitioners, Clinical Nurse Specialists, Certified Registered Nurse Anesthetists, Certified Nurse Midwives, Clinical Social Workers, Clinical Psychologist, Registered Dietitians, or Nutrition Professionals, and organizations (groups practices) consisting of any of the categories of individuals identified above, must notify Medicare provider enrollment of certain changes within thirty days.

Other changes that must be reported in 30 days are a change in practice location, change of ownership, or a final adverse action. In the event that Medicare providers do not comply with these reporting requirements relating to change of ownership, practice location, or a final adverse action, the provider may be accessed an overpayment back to the date of the final adverse action, change of practice location, or change of ownership.

Mr. Frosch is the President of Frosch Medical Consultants in Plantation, FL.  Got a Question for Ben?  Click Ask Ben  
2014 Office of Inspector General (OIG) Work Plan Physicians and other Part B Providers Print E-mail
Written by Benjamin L. Frosch   
Friday, 07 February 2014 10:53


With the passage the Affordable Health Care Act (Health Care Reform) and the Medicare program in financial jeopardy, the OIG 2014 Work Plan is possibly more important than any of their previous work plans. I would say it is one of the most detailed OIG work plans, which explains the 3 month delay of the OIG issuing the 2014 work plan.  With a few thousand staff members throughout the United States, the Office of Inspector General (OIG) plans and performs audits, investigations, evaluations, and legal activities pertaining to the Department of Health and Human Services (HHS).   With the Issuance of the 2014 OIG Work Plan there are a variety of important Medicare issues that they will evaluate pertaining to Medicare physicians and other health care providers.  This may be a good opportunity to evaluate compliance in your practice with respect to the following Part B subjects that are in the OIG Work Plan.  With more federal agencies taking a closer look at Medicare fraud and abuse than ever before, it is very clear that there is a zero tolerance for Medicare fraud and abuse.  

The following is a list of what I think are some of the hottest physician subjects targeted in the 2014 OIG Work Plan:
EVLAUATION AND MANAGEMENT SERVICES- Inappropriate payments             

This is going to be a subject under the microscope in 2014 and beyond. The OIG will be identifying providers that exhibit questionable billing for E/M services in 2010.  Medicare payments for E&M services in 2010 represented 19% of all Medicare Part B payments. The OIG will review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. Medicare has noted an increased frequency of medical records with identical documentation across services. Providers are responsible for ensuring that the E/M codes that they submit accurately reflect the services actually provided and were medically necessary.  E/M codes represent the type, setting, and complexity of services provided and the patient status, such as new or established.  


The OIG has and will continue to review physician coding on Medicare Part B claims for services performed in Ambulatory Surgical Centers (ASC) and hospital out-patient departments to determine whether they are coded properly with the correct place of service. Federal regulations provide for different levels of payments to physicians depending on where services are performed. Prior OIG reviews determined that physicians did not always correctly code non-facility places of service submitted to and paid by Medicare. Medicare pays a physician a higher amount when a service is performed in a non-facility setting, such as a physician office, than it does when a service is performed in hospital outpatient department or, with certain exceptions, in Ambulatory Surgical Centers.  

The OIG will continue to evaluate Medicare payments for Part B imaging services to determine whether they reflect the expenses incurred and whether the utilization rates reflect industry practices.  Physicians are paid for services pursuant to the Medicare Fee Schedule, which covers the major categories of cost, including the physician professional cost component, malpractice cost, and practice expenses.   Practice expenses are those such as office rent, wages of personnel, and equipment.   For selected imaging services, the OIG will focus on the practice expense components, including the equipment utilization rate. 

DIAGNOSTIC RADIOLOGY-Medical Necessity of High Cost tests

 The OIG will review Medicare payments for high-cost diagnostic radiology tests to determine whether they were medically necessary and the extent to which utilization has increased for theses diagnostic tests. They will also look again at imaging services ordered for a beneficiary by primary care physicians and physician specialists for the same treatment.

ANESTHESIA SERVICES-Payments for personally performed services  

The OIG will review the appropriateness of Medicare Part B claims for personally performed anesthesia services to determine whether they were supported in accordance with Medicare requirements. They will review whether Medicare payments for anesthesiologist services reported on a claim with the “AA” service code modifier met Medicare regulations. Physicians report the appropriate anesthesia modifier code to denote whether the service was personally performed or medically directed. Reporting an incorrect modifier on the claim as if services were personally performed when they were not will result in Medicare paying a higher amount.

OPHTHALMOLOGISTS – Questionable billing

Billing and payment issues -  The OIG plans on reviewing claims data to identify inappropriate payments and/or questionable billing for ophthalmological services during 2012. They will determine the geographic locations of providers exhibiting questionable billing for ophthalmological services in 2012. In 2010, Medicare allowed over $6.8 billion for services provided by ophthalmologists.
SLEEP DISORDER CLINICS – High utilization of sleep-testing procedures

The OIG will take a closer look at Medicare payments to physicians, hospital outpatient departments, and Independent diagnostic testing facilities (IDTF’s) for sleep–testing procedures to assess the appropriateness of Medicare payments for high utilization sleep-testing procedures and determine whether they were in accordance with Medicare requirements. An OIG analysis of CY 2010 payments for CPT codes 95810 and 95811, which totaled approximately $415 million, showed high utilization associated with these sleep-testing procedure. Diagnostic testing that is duplicative of previous testing done by the attending physician to the extent the results are still pertinent is not covered because it is not medically reasonable and necessary under the Medicare program.


The OIG will review outpatient physical therapy services provided by independent therapists to determine whether they were in compliance with Medicare reimbursement regulations. In the past, the OIG has identified claims for therapy services provided by independent physical therapists that were not, medically reasonable and necessary, or properly documented. The OIG will focus on independent therapists who have a high utilization rate for outpatient physical therapy services because of their concern that they may not be medically reasonable and necessary. 


The OIG will take a look at and review trends in laboratory utilization under Medicare, such as in the types of laboratory tests and the number of tests ordered and identify questionable billing. Medicare is the largest payer of clinical lab tests in the nation. Medicare’s payments for lab tests in 2008 represented an increase of 92 percent over payments in 1998. In 2010, Medicare paid about $8.2 billion for lab tests, accounting for 3 percent of all Medicare Part B payments.

CHIROPRATIC SERVICES - Part B payments for non covered services
The OIG will be reviewing billing and payments for chiropractic services to determine whether such payments were claimed in accordance with Medicare requirements. Prior OIG reviews identified inappropriate payments for chiropractic services during calendar year 2006. In 2013, the OIG identified unallowable Medicare payments for chiropractic services. Medicare pays only for a chiropractor’s manual manipulation of the spine to correct a subluxation if there is no neuro - musculoskeletal condition for which such manipulation is appropriate treatment. Chiropractic maintenance therapy is not considered medically reasonable or necessary, and is therefore not payable under the Medicare program.


The OIG will review Medicare claims data to identify questionable billing for electrodiagnostic testing. They will evaluate the extent to which Medicare utilization rates differ by provider specialty, diagnosis, and geographic area for these services. Electrodiagnostic testing, which assists in the diagnosis and treatment of nerve or muscle damage, includes the needle electromyogram and the nerve conduction test. The OIG is concerned about the use of electrodiagnostic testing for inappropriate financial gain poses a growing vulnerability to Medicare.

ASCs and HOSPITAL OUTPATIENT DEPARTMENTS-Safety and Quality of Surgery and Procedures

The OIG will review the safety and quality of care for Medicare beneficiaries having surgeries and procedures in ASCs and Hospital outpatient departments. They will assess care in preparation for and provided during surgeries and procedures in both settings. The OIG will identify adverse events in both settings.  

Mr. Frosch is the President of Frosch Medical Consultants in Plantation, FL.  Got a Question for Ben?  Click Ask Ben.

Last Updated on Saturday, 08 February 2014 08:20
Cardiac US, Professional Interpretation and Global Billing Print E-mail
Written by Benjamin L. Frosch   
Friday, 20 December 2013 09:54

Medicare Q & A 

Q:   I am an Administrator at a Cardiology practice that is purchasing an ultrasound machine and radiology equipment to perform procedures in our office. We will satisfy the necessary supervision requirements with a non-radiologist. However, we will have a radiologist perform the professional interpretation off-site in Jacksonville. If we hire the radiologist on a part-time basis, will our group practice be allowed to bill Medicare globally for the procedures? If not, under what circumstances can we bill globally?


Broward Cardiology Practice

A.   Let's start with the issuance of transmittal 2679 on March 29, 2013 which addresses place of service (POS) radiology services. Global billing is allowed (assumes technical/professional components are provided in the same payment locality) presupposing that the radiologist reassigned their benefits to the group.

Global billing would not be allowed when the technical is rendered in locality 3 (Broward) and the interpretation is rendered in Jacksonville (locality 2). The claim should list a line item with the technical component assigning a "TC" modifier. The professional service should be indicated as a separate line item with a "26" modifier. You would need to indicate the zip code for the professional service on the claim to Medicare since the interpretation was rendered in locality 2 (Jacksonville), which happens to have a lower payment then locality 3.
With respect to the physician working on a part-time basis in lieu of purchasing the services, you may have an issue with the Stark regulations or even some state laws. The radiologist may be required to provide these interpretations on the site of your practice. There may also be an issue with anti mark-up if these services are reimbursed on a "per test basis". You may want to check with a seasoned healthcare attorney to assure that you comply with all of these complex rules, regulations, and guidelines.

Mr. Frosch is the President of Frosch Medical Consultants in Plantation, FL.  Got a Question for Ben?  Click Ask Ben.

Last Updated on Friday, 07 February 2014 11:03
Interest Charged on Overpayments? Print E-mail
Written by Benjamin L. Frosch   
Monday, 16 December 2013 10:51

Medicare Q & A with Ben Frosch

Q:     I just received a letter from Medicare informing me of a substantial overpayment. My staff researched this issue and we concluded they are correct with the overpayment determination.  

The letter we received states that it is a follow-up letter. I never received the initial notification of an overpayment from Medicare. 
My question addresses the interest on this overpayment. What are the rules on Medicare assessing interest on an overpayment?

Miami, FL

A:     Medicare does not charge interest on overpayments that are received within thirty-days. After the thirty day period, interest is assessed for the first thirty-day period and an additional thirty-day period. Interest continues to accrue for each subsequent thirty-day period for which payment is not received by Medicare.  When money is offset (withheld from Medicare payments), it is applied to the accrued interest first and then to the principal. The follow-up overpayment letter probably does not imply you have another thirty-day period to refund the amount nor does it prevent Medicare from withholding future payments after the thirty-day period has elapsed. If you do not refund the overpayment within forty-days from the date of the initial refund request letter, Medicare may initiate offsets and pursue other efforts of recovery of the identified overpayment.

The bottom line is, once you receive notification of the overpayment; return the monies as quick as possible. The overpayment is considered a debt owed to the United States Government and you can always appeal if you feel that Medicare is incorrect with the allegations of the overpayment or the interest payment. 

About the Author 
Mr. Frosch is the President of Frosch Medical Consultants, Inc. in Plantation.  Got a question for Ben? Click Ask Ben. 

Last Updated on Monday, 16 December 2013 10:58
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