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Medicare Re-enrollment and Billing Older Claims

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Michele:
What amazes me is that this is not an unusual situation.  How do you not notice no Medicare payments for over a year??   :o

kristin:
Right? I guess if the billings to Medicare are minimal, it could escape notice. But still...kind of odd. And unfortunately, as you say, not an unusual situation, although it should be, as far as I am concerned. You run a business, you stay on top of your income/cash flow.

PMRNC:
You also want to go and get a clear audit of those claims JUST in case... :o  I would do a report and audit of all Medicare patients. That could come back to bite you in the butt later.

Scott:
I know.  When the dr told me I couldn't believe it.  I didn't want to say too much because I was trying to land the account, but I blame the dr as much as the biller.  He wasn't paying attention.   Provider was deactivated recently.  My goal is to bill as many of the claims as I can that are less than 365 days old, starting with oldest first.  What I don't know is if Medicare will allow it since the account is deactivated, even if I reactivate it.

PMRNC:
http://www.aapcps.com/news-articles/Timely-Medicare-Revalidation-May-Prevent-Deactivation-or-Revocation.aspx



Certain Changes Require Revalidation
Certain enrollment information changes, such as a change in practice location or a change in the special payments and correspondence address on file with Medicare, may affect timely compliance with revalidation requests. Medicare sends its revalidation letters and other correspondence to the special payment and correspondence address on file with Medicare. If a correspondence is returned to Medicare marked undeliverable, or if a provider does not respond to Medicare's request within the time specified in the notice, the provider's billing privileges will be deactivated or revoked.

Deactivation vs. Revocation
Deactivation of a provider's Medicare billing privileges is distinct from revocation of Medicare enrollment and billing privileges.

Deactivation is minor. Medicare may deactivate a provider's Medicare billing privileges if the provider does not report a change to the information supplied on the enrollment application within a specified time.

Significant changes include:

    a change in ownership or control (report within 30 days)
    a change in practice location (report within 30 days)
    a change in billing services (report within 90 days)
    a change in special payments and correspondence address (report within 90 days)

View the complete list of reportable changes. Additional information can be found in CFR, §424.520(b) and §424.550(b) (use your favorite online search engine to find Code of Federal Regulations, Section 424).

A provider's billing privileges will remain deactivated until the provider either:

    submits a new enrollment application (CMS 855); or
    when deemed appropriate, at a minimum, recertifies that the enrollment information currently on file with Medicare is correct. (The provider or supplier must meet all current Medicare requirements in place at the time of reactivation, and be prepared to submit a valid Medicare claim. Best practice is to contact your Medicare carrier for guidance.)

Claims for services from the date of deactivation to the date of reactivation may not be payable.

Revocation is far more serious. Revocation occurs for noncompliance, misconduct, felonies, falsifying information, and other such conditions set forth in 42 CFR, §424.535.

Revocation has devastating consequences for providers. According to CFR §424.535(a)(6)(i):

    Medicare payments will be halted and providers will be in limbo until the corrective action plan or request for reconsideration process is complete.
    The provider is barred from participating in the Medicare program from the effective date of the revocation until the end of the re-enrollment bar. What's worse, a provider may not receive the notice of revocation until months later and may continue to treat patients for a period of time, unaware that they will be forced to forfeit income when revocation is applied retroactively.
    Any provider agreement in effect at the time of revocation is terminated effective with the date of revocation.
    The re-enrollment bar is a minimum of one year, but not greater than three years, depending on the severity of the basis for revocation. (The re-enrollment bar may be waived if a provider is revoked based on failure to submit an application fee, or a hardship exception is requested with an enrollment application upon revalidation.)
    A provider or organization may be placed on the List of Excluded Individuals and Entities. (This will affect contracting with other government programs.)

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