So your business is ready to achieve Medicare Provider Designation as a Certified Provider, able to bill the Federal Medicare Program for your services?
Congratulations, this is a huge step towards your success! Along with the success there is much responsibility in billing your services to the Federal Medicare Program for reimbursement. There is the integrity of your information being submitted to the Feds on the wonderful CMS form 855, then there is also the 460, 588, and so on. Here at The Compliance Doctor, we can guide you through the maze of obtaining this national designation.
Medicare Certified & Maintaining it!
Home Health Agencies, Surgery Centers, Dialysis Centers, Congregate Living Facilities, Hospice, IDTFs, and DME companies all must become Certified as a provider that has met very specific criteria in order to obtain and maintain their certification and authorization to bill for services rendered to the Medicare Beneficiaries. The Conditions for Participation is an agreement that must be followed to the exact detail or the provider risks loosing their billing rights, thus reimbursement ceases. To appeal, fight, and obtain the right to regain this billing right is very hard, and often times the provider is unsuccessful at achieving this accolade from CMS.
Once you have achieved Medicare Certification as a provider to Medicare enrolled beneficiaries, it is imperative that you maintain a state of compliance to all the regulations. It is A LOT of work to regain this once you've allowed it to be taken from you out of ignoring the importance to keeping up on the tasks that results in your getting to keep you certified status.
De-Certified as a Medicare Provider?
How do we help? The Compliance Doctor's services in Medicare Certification and Procurement works very simply to achieve a constant state of readiness, always ready for an unannounced survey! We can do the following:
- Provide a mock survey, assessing for the standards and regulations the Medicare Program Surveyors will look for you to have in place and achieve
- For assessed deficiencies, we develop a plan of compliance to achieve the corrective measure necessary
- Prepare your business for the upcoming survey, re-validation surveys
- In the event of a decertification of Medicare, we work to bring the facility out of decertified status and regain full billing privileges by the means of proving the compliancy through re-validation of the deficiencies
- Provide the facility with any and all policies, programs, plans, and procedures necessary to achieve baseline approval from CMS
A CHOW Process must be executed
The most common example of a CHOW occurs when a provider’s CMS Certification Number (CCN) and provider agreement are transferred to another entity as a result of the latter’s purchase of the provider. To illustrate, suppose Entity A is enrolled in Medicare, but Entity B is not. B acquires A. Assuming all regulatory requirements are met, A’s provider agreement and CCN number will transfer to B.
Upon accepting the provider agreement, the new owner accepts the terms and conditions under which it was originally issued. Once the CHOW processes and the MAC: 1) receives the tie-in notice from the CMS Regional Office; and 2) updates the Provider Enrollment Chain and Ownership System (PECOS), claims will only be paid under the new owner’s tax identification number, National Provider Identifier and CCN, or provider transaction number.
MACs will no longer have the ability to update the crosswalk in order for the Seller to complete their billing. Therefore, the old and new owners are responsible for working together on payment arrangements for claims for services furnished during and before the CHOW is processed.
The updated manual language follows:
In a CHOW, the existing provider agreement is automatically assigned to the Buyer/Transferee. If the Buyer/Transferee does not explicitly reject automatic assignment before the transfer date, the provider agreement is automatically assigned, along with the CCN, effective on the transfer date. The assigned agreement is subject to all applicable statutes and regulations and to the terms and conditions under which it was originally issued. Among other things, this means that the contractor will continue to adjust payments to the provider to account for prior overpayments and underpayments, even if they relate to services provided before the sale/transfer. If the Buyer rejects assignment of the provider agreement, the Buyer must file an initial application to participate in the Medicare program. In this situation, Medicare will never pay the applicant for services the prospective provides before the date on which the provider qualifies for Medicare participation as an initial applicant.
Depending on the terms of the sale, the Buyer/Transferee may obtain a new NPI or maintain the existing NPI. After CHOW processing is complete, the Seller/Transferor will no longer be allowed to bill for services (i.e., services furnished after CHOW processing is complete) and only the Buyer is permitted to submit claims using the existing CCN. It is ultimately the responsibility of the old and new owners to work out between themselves any payment arrangements for claims for services furnished during the CHOW processing period.
The official instruction, CR9953, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/2017Downloads/R715PI.pdf.
Why hire a consultant?
We have 20 years of experiences;
We understand CMS requirements;
We know the dates and the flow of date orders they expect to see;
We know how to navigate help from CMS;
We pride ourselves on perfection first time submission;
Time is money with CHOW;
Mistakes you would make cost thousands in reprocessing the corrections;
Liaison for both CMS and Buyer;
Due Diligence for the escrow account; and
Professional MalPractice Insurance with bonding that protects you, the buyer.