Source: http://providerenrollment.net/Provider-enrollment/credentialing/
Timestamp: 2013-05-25 02:38:04
Document Index: 138445129

Matched Legal Cases: ['§ 482', '§ 485', '§ 482', '§ 482', '§ 482', '§ 485']

Credentialing | Provider Enrollment Digest
Attempt to Regulate the Provider Enrollment Process
Posted by medpro | Posted in Credentialing, Medical Contracting, Physician Credentialing, Provider Contracting, Provider Enrollment | Posted on 20-07-2011	0
An interesting bill was introduced in the State of Pennsylvania General Assembly, House Bill No. 1551 entitled The Physician Credentialing Act. The primary purpose of the act is to provide for an ”equitable and expeditions initial provider enrollment process” by “promoting fairness to the health care providers by ensuring that health insurer conduct physician credentialing in a reasonable time frame and reimburse physicians during the credentialing process.” Nobel sentiments for those of us intimately involved in the credentialing process.
the insurer must complete the initial credentialing process within 60 days of receiving a completed application.
The insure must report to the physician or designee the status of the application with 5 days of receipt telling him/her whether the insurer intends to process the application, date of the next credentialing review and an itemization of the application deficiencies.
The insurer must notify the applicant of the credentialing committee decisions with in 5 business days.
Once the insurance company has notified the applicant that they will proceed with the application, the provider will be eligible for reimbursement within 15 days of the application submittal. Reimbursement will based on the nonparticipating physician fee schedule. Or in the case of an individual joining a contracted group at the group’s current rates
An insurer must accept CAQH if submitted by a physician.
A insurer not adhering to these new rules is liable for damage claims made by physicians plus they can incur a $5,000 state penalty.
A physician has the right to appeal to the State Secretary of Health an application rejection, under certain circumstances.
Some interesting issues here, although it appears to apply to physicians only and it is a bit one sided in that regard. Not sure that the insurance companies will be pleased with all these new restrictions and controls, so there may be some struggles and/or changes along the way. However it is encouraging to see recognition by lawmakers of the difficulties and complexities associated with the provider enrollment process. Difficulties and complexities on both sides of the transaction and that a bit of standardization could help resolve some of the more egregious. We wish them well.
What do you think about the Bill and it’s prospect for passage? Leave a comment.
New Telemedicine Provider Enrollment Procedures
Posted by medpro | Posted in Credentialing, Physician Credentialing, Provider Enrollment | Posted on 01-06-2011	0
As mentioned in a previous post the CMS has instituted new rules regarding provider enrollment requirements for telemedicine applications. Under the previous system, a provider supplying the telemedicine service would need to be credentialed at both medical facilities. This created an unnecessary level of paperwork, time and duplication of effort. The CMS recognized the problem and issues the new rules which allows the receiving hospital to accept the credentials of the telemedicine providing entity. However there are some procedures and caveats that apply.
There are two sets of rules that apply one for hospitals and the other for independent telemedicine entities (ie non-hospital provider organizations that offer telemedicine services). There must be a written agreement between the providing and the receiving medical entity. That agreement must contain certain provisions. For hospitals the lists include the following:
The physician providing the telemedicine services must be privileged at the originating hospital and that hospital must provide a list of those privileges. The hospital providing the telemedicine services must be medicare participating.
The physician providing the services must be licensed in the state where the patient is receiving the telemedicine services.
The hospital receiving the telemedicine services must submit a performance review of the telemedicine to the originating hospital.
The privileging hospital must adhere to the standards set out in 42 C.F.R. §§ 482.12(a)(1)-(7) , 42 C.F.R. §§ 485.616(c)(1)(i)-(vii) and 42 C.F.R. §§ 482.12(a)(8), 482.22(a)(3) and 485.616(c)(2). With telemedicine entities again both parties must enter into a written agreement that include the following provisions.
The physician must be privileged at the entity that providing the telemedicine services and that entity must provide a list of those privileges.
The providing telemedicine entity must comply with all CoP’s related to providing a contracted medical services.
The credentialing standards of the telemedicine entity must meed the standards set out in 42 C.F.R. §§ 482.12(a)(1)-(7) and 42 C.F.R. §§ 482.22(a)(1)-(2) or 42 C.F.R. §§ 485.616(c)(1)(i)-(vii).
Again the physician/provider must be licensed in the state where the patient is receiving the service.
The same internal review procedures as is the case with hospitals.
It important that both parties participating in a telemedicine relationship spent a bit of time up front to insure that the written agreement is in order and that the proper provider enrollment standards are in place.
New Telemedicine Physician Credentialing Rules Released
Posted by medpro | Posted in Credentialing, Physician Credentialing, Provider Enrollment | Posted on 10-05-2011	0
The CMS announced on May 5 2011 that it has finalized new rules for telemedicine services that will simplify the the provider enrollment and credentialing process. These changes were made to help ensure that patients, especially in rural or remote areas, will receive the best possible medical care from their local hospitals by making it easier for small and critical access hospitals (CAHs) to use telemedicine to link with physicians and other larger hospitals or academic medical centers. Under the old system practitioners could not provide care via telemedicine unless they were granted practice privileges both by their home hospital as well as by the remote hospital or CAH to which the telemedicine services were being delivered. Small hospital simply lacked the staff and resources to credential and privilege physicians participating the the telemeidicne services from remote hospitals.
Under the new rules each hospital and CAH will no longer be required to credential and grant privileges to each individual physician and practitioner who provides telemedicine services to its patients from a distant hospital or other telemedicine location. Instead, hospitals can employ the credentialing and privileging decisions of the distant hospital where the provider is currently privileged. The changes allow for what amounts to facility-to- facility credentialing and privileging as opposed to facility-to-physician. One caveat, the CMS telemedicine credentialing and privileging Conditions of Participation have been particularly challenging for hospitals using Joint Commission (TJC) accreditation for deemed status. That is because hospitals using the TJC “privileging-by-proxy” telemedicine standards have not technically been meeting CMS requirements – a situation which has obviously been problematic and confusing for hospitals. While the CMS final rule does more closely align with TJC “privileging-by-proxy” concept it is not yet clear how the new CMS regulations and TJC standards will align. While TJC is expected to conform to CMS regulations, you may want to wait for a response from TJC before implementing any changes. The final rule goals are to reduce the burden of the traditional provider credentialing and enrollment process for Medicare-participating hospitals and CAHs, both those that provide telemedicine services and those that use such services. In particular, the rule extends the option of a streamlined credentialing and privileging process to those small hospitals and CAHs that use the telemedicine services in order to improve access to specialty services for patients.
New, Strict Provider Enrollment Rules for DMEPOS Suppliers
Posted by medpro | Posted in Credentialing, Provider Contracting | Posted on 11-04-2011	0
The DMEPOS supplier industry has been singled by the Inspector General of the Department of Health and Human Services,Daniel Levinson, as an area of heightened fraud related concern. He noted during congressional testimony that, over the last three decades, HHS-OIG has detected “significant levels” of fraud and abuse related to durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). In addition, many DMEPOS suppliers are highly dependent on federal healthcare programs for revenue and CMS believes that a number of these types of providers enter business without any substantial clinical or business experience which in turn leads to a high level of non-fraud related errors and omissions. To help reduce these problems new, more stringent rules regrading DMEPOS provider enrollment and recertification have been enacted. The new rules went into effect on March 25, 2011.
As part of the new regulatory environment risk assessment categories of “limited”, “moderate” and “high” have been created. (More information here about the new classifications). Under the new rule currently enrolled DMEPOS suppliers will be automatically assigned to the “Moderate Risk” category while any new suppliers or those adding a new location will be assigned to the “High Risk” Category.
The practical applications of these category assignments are a significant, increasing the time and paperwork involved in newly enrolling entity’s credentialing process. The new procedures include extensive data base searches, including “The List of Excluded Individuals or Entities” and “ The Exclude Parties List” system of the GSA. On-site inspections will likely increase with Medicare contractors, The National Supplier Clearinghouse (authorized for both pre and post enrollment visits) as well as any national accreditation organization and state agencies with jurisdiction having the right and/or obligation to pay the supplier’s offices a visit. Criminal background checks of owners as well as fingerprinting of of all owners and managing employees are authorized.
For revalidating entities who are automatically assigned to the “Moderate Risk” category the process of making sure all the regulatory and licensing issues are current and up to date, while not quite as difficult, will likely be more through and time consuming. They too will be subject to on going data base checks and unannounced site visits.
In addition, if any existing DME supplier is subject to any of the issues detailed below they will be reassigned to the “High Risk” category and subject to the same provider enrollment restrictions.
In addition to all of the above, the certification standards have also be tightened
All DMEPOS suppliers must obtain oxygen for state-licensed suppliers, where required
All DMEPOS suppliers must maintain ordering and referring documentation for 7 years of the date of service
All DMEPOS suppliers are prohibited for sharing a practice location with any other medicare suppler or provider except in the the case of Medicare Part A providers or where a medical provider furnished the items to his or her own patients.
All DMEPOS suppliers must be open at least 30 hours per week.
All of these restrictions and new provider enrollment procedures are designed to stop what is seen to be the egregious level of abuse encountered within the industry. While these problems do surely exist, the net result will be a substantial increase in the complexity associated with future Medicare authorization for both the good and the bad. These complexities will add significant time and cost to the process. DMEPOS suppliers and those responsible for their enrollment activities should take note and plan accordingly.