December 16, 2019

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Centers for Medicare & Medicaid Services (CMS) to Deny Claims When Ordering/Referring Provider Not Enrolled in Medicare

Effective May 1, 2013, the Centers for Medicare & Medicaid Services (CMS) will begin to deny Part B Durable Medical Equipment (DME) and Part A Home Health Agency (HHA) claims for services or supplies when the ordering/referring practitioner (1) does not have a current Medicare enrollment record with a valid National Provider Identifier (NPI) or (2) is of a type that is not eligible to order or refer for Medicare beneficiaries. 

This change reflects the implementation of a long-delayed initiative to ensure Medicare only pays for items and services ordered by an authorized practitioner.  Since October 2009, CMS has alerted billing providers when the identification of the ordering/referring practitioner was missing, incomplete or invalid, or when the ordering/referring practitioner was not eligible to refer.  However, such claims were not denied, and the date for implementing denials was extended while CMS established initiatives to ensure physicians and non-physician practitioners were aware that they must have a current Medicare enrollment record with a valid NPI.  CMS also has implemented a special enrollment form (CMS-855O) for physicians and non-physician practitioners who do not themselves submit claims, so items and services they order or refer for will not be denied.  

Providers and suppliers who bill Part B DME and HHA claims need to ensure the physicians and non-physician practitioners they accept orders and referrals from have current Medicare enrollment records and are of a type/specialty that is eligible to order or refer in the Medicare program.  Providers and suppliers may review this information on the Ordering Referring Report.

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About this Author

Joan Polacheck, Health Care industry Lawyer, McDermott Will Emery, Chicago Law Firm

Joan Polacheck is a partner in the law firm of McDermott Will & Emery LLP and is based in the Firm’s Chicago office. She represents a broad range of health care industry clients, including hospitals, suppliers, and drug and device companies.

Monica Wallace, regulatory counseling lawyer, administrative attorney, McDermott Will Emery, law firm

Monica A. Wallace is an associate in the law firm of McDermott Will & Emery LLP and is based in the Firm’s Chicago office.  She focuses her practice on complex regulatory and transactional counseling to health care organizations such as health systems, hospitals, physician groups, integrated delivery systems, durable medical equipment prosthetics and orthotics suppliers, home health agencies, and other health care providers. Monica’s regulatory practice focuses on the Anti-Kickback and Stark laws; Medicare and Medicaid reimbursement and billing; legal assessments and compliance programs; and other general regulatory matters including licensure, survey/certification, and accreditation. Her transactional practice includes mergers, acquisitions and affiliations; divestitures; hospital/physician joint ventures; and corporate reorganization.