How Part B Claims Can Result in Enrollment Deactivation and an Enrollment Conundrum
Health centers are unique for a whole host of reasons including how they get paid from
Medicare. The Prospective Payment System (PPS) G codes trigger encounter rate payment for
all employed providers. By employed we mean 1099 or W-2 staff. In fact, it is well established
that all new providers who are not completely enrolled can from day one of employment be
paid to see patients whose services are covered under encounter rate. So, for Medicare PPS G codes or T1015 Medicaid encounter rate payment, life is good.
What is not so good is deactivation of Part B status as well as any associated PTAN because of no claim activity. As a taxpayer, I love this. Let’s delete an inactive NPI to mitigate opportunity for nefarious activity. We don’t want criminals using inactive NPIs to defraud payers, governmental or otherwise.
Per CMS policy, if there is no Part B claim activity for 12 months, the NPI is deactivated. The same policy above says that if a number is deactivated, the only way to re-instate the active status is to reapply. In CMS parlance, to regain active status an individual needs to submit a new 855-I (individual Medicare enrollment application) every year.
No Part B claim activity means no 837-P claims filed. The “P” indicates professional vs. institutional claim format. The institutional claims (i.e., 837-I) are processed by Part A when the Medicare Administrative Contractors (MACs) pay the PPS G codes. Most health center providers such as doctors, NPs, and PAs submit at least some claims to Part B via the 837-P. Such Part B services include CLIA-waived labs like a urine dip (HCPCS 81002) or technical component of an electrocardiogram (HCPCS 93005). Other provider types like Clinical Social Workers or psychologists will never submit Part B claims. Again, no Part B clams results in deactivation of participation which means submitting an 855-I every year to maintain active status.
One might reasonably ask: “Who cares if the status is deactivated if they never submit Part B claims to Medicare? A couple of short answers:
Part A PPS G code claims have been denied by MACs when the rendering NPI is inactive.
Medicare Advantage (and other commercial plans) require/expect active Part B status to maintain inclusion on their respective participating provider lists.
After calling a few MAC enrollment departments and chatting with supervisors, it was communicated that CMS recently completed a massive project that resulted in large-scale deactivations. So, if you have not seen nor heard of this issue at your health center, we recommend preparation and/or research to see if your providers are impacted. Personally, I am communicating with PCA and NACHC colleagues to see if CMS might be lobbied to modify policy to allow health centers to verify with a MAC that a provider is active even if s/he does not submit Part B claims. It is not easy to get CMS to change policy but with thousands of impacted providers, maybe they will listen.
If all this credentialing/enrollment is too much to think about, certainly outside expertise exists. Find a consultant to assist your team and/or consider an outsourced relationship with a company like PMG Credentialing. Either way, this is just one more example of the complexities of healthcare keeping healthcare revenue cycle professionals gainfully employed.