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Out of bounds: When you move, be sure to let Medicare know
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From international law firm Arnold & Porter LLP comes a timely column that provides views on current regulatory and legislative topics that weigh on the minds of today’s physicians and health care executives.
Alexander R. Cohen
When asked what their practice’s most important asset is, most ophthalmologists will respond with a nod to their top-notch office personnel or new femtosecond laser or loyal patients. However, perhaps no greater asset exists for an ophthalmological practice than its Medicare participation agreement. It is the foundation of a successful and stable practice upon which careers are built. But if it is handled recklessly, this valuable contract with CMS can be revoked for any number of reasons, and everything built upon it can quickly, and without warning, come crumbling down. Making matters worse, as a result of the Affordable Care Act, revocation of a physician’s Medicare enrollment triggers termination of the provider’s enrollment in state Medicaid programs, renders the provider ineligible to participate in Medicare Part C, and may even erode relationships with private managed care plans. And, rounding out the nightmare scenario, many states have enacted laws that require revocation of a provider’s professional license if that provider is excluded from the state’s Medicaid program.
Alan E. Reider
One common but easily avoidable cause of Medicare revocations is failed on-site reviews after an office move or change of ownership. A provider in the Medicare program must be “operational” to furnish Medicare-covered items or services. A provider is operational when, among other things, it has a qualified physical practice location and is open to the public for the purpose of providing health care-related services. At its discretion, CMS may perform an on-site inspection to verify the accuracy of a provider’s Medicare enrollment application (form 855) information and to determine if a provider is, indeed, operational, as required by Medicare regulations. If, upon inspection, Medicare determines that a provider is not practicing at its qualified physical practice location — that is, the practice location identified in the provider’s form 855 — the provider will be deemed non-operational and CMS may revoke the provider’s Medicare enrollment and billing privileges. And, as counterintuitive as it may be, submitting informal notice of a changed address will offer little protection from this draconian result. When contemplating a change of office location, it is critical that providers and enrolled practices are aware that they must submit to CMS a form 855 containing the updated information, within 30 days of the change. A simple submission, without a substitute. Ignore it at your own peril.
Alexander R. Cohen, JD, an associate at Arnold & Porter LLP, can be reached at alexander.cohen@aporter.com.
Alan E. Reider, JD, MPH, a partner at Arnold & Porter LLP, can be reached at alan.reider@aporter.com.