CMS Announces Changes to Physician Enrollment Policies

CMSEffective March 18, 2015, CMS made changes to their Provider Enrollment policies and incorporated them into Chapter 15 of the Program Integrity Manual.  The changes were made under the final rule titled, “Medicare Program; Contract Year 2015 Policy and Technical Changes to the Medicare Advantage and the Medicare Prescription Drug Benefit Programs,” focusing on physicians and eligible professionals who prescribe Medicare Part D drugs, and for providers and suppliers that submit claims to Medicare Administrative Contractors (MACs) for services provided to Medicare beneficiaries.  The changes, as published in the MLN Matters® Number MM8901, are summarized below:

If a MAC approves a provider’s or supplier’s Form CMS-855 (enrollment) reactivation application or Reactivation Certification Package (RCP) for a Part B non-certified supplier, the reactivation effective date will be the date the MAC received the application or RCP that was processed to completion. Also, upon reactivating billing privileges for a Part B non-certified supplier, the MAC will issue a new Provider Transaction Access Number (PTAN).

CMS may deny a physician’s or eligible professional’s Form CMS-855 enrollment application under § 424.530(a)(11) if:

  • The physician’s or eligible professional’s Drug Enforcement Administration (DEA) Certificate of Registration to dispense a controlled substance is currently suspended or revoked; or
  • The applicable licensing or administrative body for any state in which the physician or eligible professional practices has suspended or revoked the physician’s or eligible professional’s ability to prescribe drugs, and such suspension or revocation is in effect on the date the physician or eligible professional submits his or her enrollment application to the Medicare contractor.

CMS may revoke a physician’s or eligible professional’s Medicare enrollment under § 424.535(a)(13) if:

  • The physician’s or eligible professional’s DEA Certificate of Registration is suspended or revoked; or
  • The applicable licensing or administrative body for any state in which the physician or eligible professional practices has suspended or revoked the physician’s or eligible professional’s ability to prescribe drugs.

CMS may revoke a physician’s or eligible professional’s Medicare enrollment under § 424.535(a)(14) if:

CMS determines that the physician or eligible professional has a pattern or practice of prescribing Part D drugs that falls into one of the following categories:

  • The pattern or practice is abusive or represents a threat to the health and safety of Medicare beneficiaries or both.
  • The pattern or practice of prescribing fails to meet Medicare requirements.

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