Take The Guesswork Out Of Medicare Provider Enrollment

With nearly 67 million members, Medicare is the largest healthcare insurance entity in the U.S. – dwarfing Kaiser Permanente, the biggest private payer serving 8.2 million enrollees. But Medicare provider enrollment – like signing up with any private payer – isn’t a walk in the park. Enrolling a single provider with Medicare typically takes 4-8 hours of uninterrupted time. Credentialers must collect an average of 30 documents per provider, which boosts the total time to an average of 10 hours.

Completing Medicare credentialing requires specific forms and meticulous attention to detail that can trip up even the most diligent credentialer. This blog will outline the Medicare provider enrollment process and discuss how technology speeds up application approval.

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Who Can Enroll Providers With Medicare?

There are three categories under which a healthcare organization can submit Medicare provider enrollment applications with the Centers for Medicare and Medicaid Services (CMS):

• Institutional Providers: Hospitals, critical care facilities, skilled nursing facilities, home health agencies, rural health clinics, Federally Qualified Health Centers (FQHC), and hospice programs that provide services to Medicare beneficiaries.
• Part B Suppliers: Laboratories, clinics, physical therapists, clinical social workers, and non-physician practitioners.
• Provider and Supplier Organizations: Business structures, like corporations, partnerships, professional associations, or limited liability companies, which meet the provider and supplier definitions. Provider and supplier organizations don’t include organizations the IRS defines as sole proprietorships.

How do you know what category is right? The Medicare application portal lists questions to guide you to the choice that best fits your needs. It is critical to answer the questions correctly. You must redo the entire process if you submit the wrong form. Ask these questions when completing the application:

• Application Type: Are you submitting an institutional clinic or group individual application?
• Ordering Referring Prescribing: Does your facility need to be directly credentialed, or are you applying for new medical residents at the start of their careers?
• Tax Designation and IRS Setup: Are you a sole proprietor or an LLC disregarded entity?

How To Become a Medicare Provider

Unfortunately, completing Medicare provider enrollment can seem like a never-ending maze. But, I’ve broken it down for you below and here’s a guide that can help out.

Gather Medicare Credentialing Requirements

Medicare credentialing requires comparable primary source verification (PSV) steps as expected by commercial payers. These are some of the items that you’ll want to have on hand (and verified) before submitting your Medicare enrollment application.

• Practitioner degree (MD, DO, DPM), post-graduate education or training
• Details of medical or professional education and training
• Current license or certification in the state(s) in which the care provider will be practicing (no temporary licenses)
• National Provider Identification (NPI) number
• Active Drug Enforcement Agency (DEA) number and/or Controlled Dangerous Substance (CDS)
• Medicare/Medicaid participation eligibility or certification (if applicable)

In addition to these basic requirements, CMS also asks for the following information:

• Copies of all final adverse legal action documentation
• Completed form CMS-460, Medicare Participating Physician or Supplier Agreement
• Completed formm CMS-588, Electronic Funds Transfer Authorization Agreement
• Written confirmation from the IRS confirming your Tax Identification Number and Legal Business Name
• Written confirmation from the IRS if your business is registered as a LLC
• Copy of IRS determination letter if you are registered with the IRS as a non-profit

Update Your Information

You need a National Provider Identifier Standard (NPI) number prior to application. This is a unique identification number for covered healthcare providers that are issued through the National Plan & Provider Enumeration System (NPPES). Not sure if you have an NPI? Search the NPI Registry. Ensure your legal business name and individual provider names are up-to-date and accurate before starting. If the data in NPPES and PECOS (Provider, Enrollment, Chain, and Ownership System) don’t match, the application will be sent back (causing enrollment delays). It’s also important to know that updates to a provider’s NPI record in NPPES do not automatically update in PECOS.

Download this checklist for more tips like this.

Complete the Medicare Provider Enrollment Application

According to CMS timelines, you can save 15 days by enrolling using PECOS instead of submitting the provider Medicare enrollment application online. As a reminder, make sure you already have an NPI before you start the Medicare provider application. You’ll also want to double check all data before submission – especially the enrollment type – so you don’t delay or invalidate the process.

Work With Your MAC

A Medicare Administrative Contractor (MAC) is a private healthcare insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries. Your MAC is specific to the region where you practice and may have additional requests for information while they process your application. You can also check in with your MAC regarding your enrollment status.

Following Application Submission

• Check the application at one week
• Check the application at two weeks
• Obtain credentialing approval via the portal
• Receive your Medicare P-TAN (Provider Transaction Access Number)

Once the application is submitted to Medicare, you play the waiting game to see if CMS approves, denies, or rejects enrollment. A denial or rejection means you start over. Getting it right the first time is essential – and that’s where credentialing software is invaluable.

Use Credentialing Software To Simplify Medicare Provider Enrollment

Medicare provider enrollment can be a long, complex process. Credentialing and enrollment software incorporates automation and standardized workflows that speed up the process. Here’s some of the automation you should look for:

• Automated form fill and extraction: Upload forms to the provider enrollment software and data is automatically extracted and stored, then when you’re ready to complete the Medicare provider application, AI-powered mapping takes care of that for you in seconds.
• Automated reminder emails: Add Medicare revalidation dates to the software for automated reminders to both the credentialing specialist and the provider, so you don’t miss the deadline – CMS does no offer extensions!
• Automated license verification: Rely on credentialing software to access original sources on demand and populate license data and an image right within the platform.

The real-time reports and dashboards available in credentialing platforms offer incredible insight to the process so you know how long Medicare provider enrollment takes on average for your organization. They’re also a great way to identify gaps, process improvements, and documents ready to expire.

Ready to tackle Medicare credentialing? Contact MedTrainer to speed up your process.