Enrolling with the Medicare program involves the various CMS-855 forms.  There are now seven different forms that must be used by different providers of healthcare services or products.  These forms are long, detailed and sometimes confusing.  Not only must they be filed initially for given provider, they must be maintained and updated as appropriate.  Due to the increasing complexity of healthcare delivery systems, providers, such as integrated delivery systems or large multi-specialty clinics, may have to maintain hundreds of these forms.  The Medicare program uses a revalidation process to periodically require all healthcare providers to resubmit their various 855 forms in order to assure that compliance is being maintained.  Over time the use and guidance for the enrollment process continues to morph even though there is no change in guidance.  This occurs through interpretations and clarifying guidance.

  • What are these CMS-855 forms?
  • What is this newer CMS-855-POH form?
  • How is enrollment affected by the revalidation process?
  • Why is the Medicare Program so sensitive to enrollment?
  • Where do I find the official regulations for Medicare enrollment?
  • Do we have to use PECOS?
  • Are there any problems with the Cycle 2 revalidation process?
  • How can we check to see who needs to be revalidated?
  • Are there really on-site audits relative to enrollment?
  • What are these opt-out physicians and practitioners?
  • How is Part D coverage involved with these CMS-855 forms?
  • How are we supposed to keep track of all these CMS-855 forms?
  • What are the compliance risks relative to Medicare enrollment?
  • What about Medicare Advantage programs and the 855 forms?

Session Objectives:

  • To review the Medicare enrollment process through the use of the various CMS-855 forms.
  • To address changes to the CMS-855 forms and/or changes in interpretations of the forms.
  • To discuss the revalidation process for the various CMS-855 forms.
  • To briefly review the CMS Conditions for Payment (CfPs).
  • To appreciate the Medicare concerns surrounding billing and payment for services and supplies.
  • To review organizational structuring changes such as with provider-based clinics.
  • To review the purpose and use of the six different CMS-855 forms along with the new CMS-855-POH.
  • To understand the concept of opt-out physicians and practitioners.
  • To appreciate how opt-out physicians can and/or should enroll in the Medicare program.
  • To appreciate how Part D coverage is impacted by the enrollment process.
  • Why are the fuss about ordering/referring physicians?
  • To understand the revalidation process and associated challenges.
  • To appreciate how other required reporting, such as the NPIs and Provider-Based reporting connect with the Medicare enrollment.
  • To recognize the need to develop organizational resources to maintain multiple CMS-855 forms.
  • To appreciate the proper use of the Internet-based PECOS process.
  • To appreciate current and anticipated changes for maintaining billing privileges with Medicare.
  • To understand how the Medicare Advantage programs (Part C) fit into the CMS-855 forms.
  • To work through several case studies.
  • To recognize the need to establish contact with knowledgeable personnel at the MAC and/or RO.

Session Agenda:

  1. Introduction
    1. Conditions for Payment – 42 CFR 424
    2. Definitions – Provider vs. Supplier
    3. Claims Filing Process
    4. Reassignment of Payments
    5. OIG Investigations Concerning Fraudulent Billing
    6. Revalidation and Billing Credentialing
    7. Opt-Out Physicians and Practitioners
  2. Review of the CMS-855 Forms
    1. CMS-855-A
    2. CMS-855-B
    3. CMS-855-I
    4. CMS-855-O
    5. CMS855-R
    6. CMS-855-S
    7. How the CMS-855 Forms Relate to Each Other
    8. Newer CMS-855-POH – Annual Report Physician Ownership
    9. National Provider Identifiers- NPIs
    10. Tax Identification Numbers – TINs
  3. Opt-Out Physicians/Practitioners
    1. What Is the Process
    2. Why Would a Physician/Practitioner Opt-Out?
    3. How do Opt-Out Physicians Affect Hospitals/Clinics?
    4. How Does the CMS-855-O Fit Into This Process?
  4. Revalidation Process
    1. Revalidations Cycles
    2. Cycle 1 Process
    3. Cycle 2 Process
    4. Determining Status and Notification
    5. Time Frames for Completion
    6. Risk Levels
    7. On-Site Visits
  5. Addressing Changing Organizational Structuring
    1. Impact of Organizational Structuring on Enrollment
    2. Integrated Delivery Systems
    3. Multi-Specialty Groups
    4. Provider-Based Clinics/Operations
    5. Maintaining NPIs and TINs
    6. Other Related Reporting Requirements
  6. Utilizing PECOS versus Manual Submission
  7. Case Studies
  8. Future Requirements for Conditions for Payment
Related Courses:

Suggested Attendees:

  • Healthcare Execurtives
  • Claim Filing Personnel
  • Coding and Billing Personnel
  • Compliance Personnel
  • Financial Personnel
  • Accreditation and Licensing Personnel
  • Physicians
  • Non-Physician Practitioners
  • DME Suppliers
  • Clinics
  • Cost Report Personnel
  • Other Personnel Interested in Billing Privileges with the Medicare Program

About The Presenter:

Duane C. Abbey, PhD, CFP, is a management consultant and president of Abbey & Abbey Consultants, Inc., a consulting firm specializing in health care and related areas. Duane earned his graduate degrees at the University of Notre Dame and Iowa State University and has more than 20 years of experience as a consultant. Dr. Abbey works extensively in all areas relating to compliance reviews,coding, billing and reimbursement with particular emphasis on the chargemaster and outpatient payment. His consulting activities include hospitals and physicians based clinics.

In addition to his consulting practice, Dr. Abbey also teaches workshops and makes presentations on a regular basis. He has taught at the University level and speaks nationally. He is a regular presenter for hospital associations, medical societies, Boards of Trustees and various other organizations and groups. In addition, professional societies such as HFMA use Dr. Abbey’s services to present seminars and workshops.

Dr. Abbey is a nationally recognized expert in payment systems. A special area of expertise includes APGs/APCs. He is recognized as the leading expert in the nation in APGs/APCs by the thousands who have attended his seminars, read his publications and/or contracted for his services. Attendees at these seminars over the years have included personnel from hospitals, clinics, integrated delivery systems and multiple consulting firms.

Dr. Abbey is also the author of numerous articles and books including: Compliance for Coding, Billing & Reimbursement, Outpatient Services: Designing, Organizing & Managing Outpatient Resources, ChargeMaster: Review Strategies for Improved Billing and Reimbursement, Ambulatory Patient Group Operations Manual, published by McGraw-Hill and Non-Physician Providers: Guide to Coding, Billing & Reimbursement, Chargemasters: Strategies to Ensure Accurate Reimbursement and Compliance, and Emergency Department Coding &Billing: A Guide to Reimbursement & Compliance published.


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