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

The Centers for Medicare & Medicaid Services will implement edits on providers ordering/referring Part B, durable medical equipment and Part A home health agency claims effective January 6, 2014.

Effective January 6, 2014, the Centers for Medicare & Medicaid Services (CMS) will deny Part B clinical laboratory and imaging, durable medical equipment prosthetics, orthotics and supplies (DMEPOS) and Part A home health agency (HHA) claims, unless the ordering/referring physician or non-physician practitioner: (1) has a current Medicare enrollment record with a valid National Provider Identifier and (2) is of a type that is eligible to order/refer items or services for Medicare beneficiaries.

Providers and suppliers affected by this requirement include clinical laboratories, independent diagnostic testing facilities, portable x-ray facilities, radiation therapy centers, DMEPOS suppliers and HHAs.  Providers and suppliers may check the Ordering/Referring Report, available on CMS’ website, to determine whether physicians and non-physician practitioners who order/refer Part B DME and/or Part A HHA items and services have current Medicare enrollment records and are of a type that is eligible to order/refer.

Physicians, physician assistants, clinical nurse specialists, nurse practitioners, clinical psychologists, interns, residents, fellows, certified nurse midwives and clinical social workers may order/refer certain items or services for Medicare beneficiaries.  However, HHA services may only be ordered/referred by a physician with an M.D., D.O. or D.P.M.  Optometrists may only order/refer certain DMEPOS products and services and laboratory and x-ray services payable under Part B.  Chiropractors are not eligible to order/refer items or services for Medicare beneficiaries.

The edits are effective for claims with dates of service on or after January 6, 2014.  Claims denied because they failed the ordering/referring edit cannot be billed to a Medicare beneficiary. As a result, CMS advises that an Advance Beneficiary Notice is not appropriate.  Providers and suppliers whose claims are denied as a result of the edits may file an appeal through the standard claims appeals process or work with their A/B or DME Medicare Administrative Contractor.

The original implementation date of the ordering/referring practitioner edits was April 2, 2010.  The implementation date has been postponed multiple times and, while further delays are possible, it appears that the systems are now in place to implement the edits as of the January 6, 2014, effective date.

© 2019 McDermott Will & Emery

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About this Author

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

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.

312-984-7556
Monica Wallace, regulatory counseling lawyer, administrative attorney, McDermott Will Emery, law firm
Associate

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.

312-984-7757