War and Medicare Enrollment

Combat is often described as hours of boredom intermixed with moments of sheer terror. 

I fear that that metaphor is increasingly applicable to Medicare enrollment. Few things in life are more boring than the Centers for Medicare & Medicaid Services (CMS) enrollment applications. There is simply no way to make Medicare enrollment fun. Alas, “boring” and “unimportant” are not synonyms.  

You will discover this quickly if you get a letter indicating that your billing number has been retroactively revoked 18 months earlier, and you are facing a 10-year enrollment bar because you failed to include a medical director or nursing supervisor on your 855 form. In case that snuck by, I will repeat it. The organization may lose the last 18 months of reimbursement and be barred from billing for a decade. It’s the sort of letter that shortens your lifespan.  

I reviewed one such letter last week. For many types of administrative errors, there are two very different options for addressing the situation. If you believe that the Medicare Administrative Contractor misunderstood the facts, you could appeal. But if the MAC is correct, and you had failed to submit some required information, they would offer a plan of correction. In essence, you apologize, fix the form, and life continues pretty much as normal. That seems like the right approach for a relatively minor administrative error.

But this letter does not offer the option of a plan of correction. This is an enormous problem because administrative law judges (ALJs) are not really empowered to accept your apology, and it isn’t clear that they can rule that a penalty is excessive given the circumstances. 

If an ALJ finds that the MAC has properly described the facts and imposed a penalty that is permitted by law, you can assume that the ALJ will uphold the penalty. The plan of correction has been the tool that prevents minor administrative mistakes from resulting in the Medicare death penalty.   

All indications are that 855 forms are now some type of Russian roulette. Ministerial errors can end an organization’s Medicare enrollment. In this instance, for another ten years.     

So, what does this mean?  

You need to look at the 855 forms you have submitted carefully. It is easy to forget to submit corrections. Small things, like a five percent change in ownership triggers a need to update the form. If you are in a clinic with fewer than 20 shareholders, every single buy-in or buy-out will trigger the need to update your 855 form.

Any change in your management team similarly necessitates updates to the form. When you open or close a new office location? You better tell CMS.  

Increasingly, it seems like missing something may be an existential error. I certainly would not consider the failure to submit a form telling CMS of a new nursing director as “fraud.” But it seems the government is more than willing to act as if it is, imposing draconian consequences. 

If you haven’t prioritized your 855 forms, it is time to do so now.