Enrollment in the Medicare program progressively has become more involved over the years. This process is accomplished through the use of various CMS-855 forms. On July 1, 2011 CMS quietly updated the CMS-855 system and switched from five different forms to six by adding the CMS-855-O. The "O" refers to "ordering," or referring. The six forms with abbreviated titles are:

• CMS-855-A - Hospitals
• CMS-855-B - Clinics
• CMS855-I - Individuals
• CMS-855-O - Ordering/Referring
• CMS-855-R - Reassignment
• CMS-855-S - DME

During the last decade CMS has been progressing through a rather lengthy procedure to update and refine the overall process of enrolling in the Medicare program. Medicare enrollment has been an investigative target, particularly in terms of fraudulent enrollment and subsequent fraudulent billing of Medicare. One of the more significant areas of focus has been DME.

The GAO has encouraged CMS to continue to improve the process of enrollment to help curtail fraud. For instance, in a July 25, 2011 report, "Improper Payments - Reported Medicare Estimates and Key Remediation Strategies," one of five recommendations was:

"Strengthen provider enrollment standards and procedures. Strong standards and procedures can help reduce the risk of enrolling providers intent on defrauding the program. CMS has taken action to implement provisions of the Patient Protection and Affordable Care Act by screening providers by levels of risk and providing more stringent review of high-risk providers, but has yet to implement certain GAO recommendations in this area."

The GAO gave CMS credit for making certain changes, but the GAO certainly is encouraging CMS to do more in this area. As we shall discuss briefly, CMS is making the process of enrolling in the Medicare program more rigorous in various ways, including by introducing a new revalidation process.

Current enrollment activities are the end result of work conducted by CMS through the April 25, 2003 Federal Register, which proposed changes that were finalized in the April 21, 2006 Federal Register. Note that CMS had to hurry to publish this final Federal Register in order to meet the three-year deadline created by MMA 2003.⁽¹⁾ During the last several years there have been additional modifications to the provision addressing the CMS Form 855 processes. For instance, the revalidation cycle initially was set at every three years, but this since has been changed to every five years.

CMS periodically issues Federal Register entries discussing various aspects of the provider enrollment process. The most recent of these is in the February 2, 2011 Federal Register, pages 5862-5971 (76 FR 5862-5971). Yes, this is a 110-page Federal Register entry. Also, CMS is providing additional information through national phone calls.⁽²⁾ Needless to say, there are extended discussions in this Federal Register, including mention of the new risk screening categories. Among the many concepts referenced is that hospitals, but not physicians, will have to pay a fee when filing a new CMS-855-A or revalidating their current CMS-855-A. The fee for 2012 is $523.

Again, the newest CMS-855 form is the 855-O. There were several reasons why CMS developed this form and made it available. The most immediate reason is to address physicians and practitioners who may not need to enroll with Medicare directly, however, these same physicians may need to be recognized for ordering services or referring Medicare beneficiaries for services. For example, a physician at a VA hospital may not need to file claims with Medicare directly, but this same physician may order services and/or refer patients for services. One of the claims filing requirements CMS very much wants to implement is to mandate that the service provider report the NPI for the ordering or referring physician/practitioner.

The CMS-855-O also makes life a bit easier for opt-out physicians and practitioners. With Medicare reducing physician reimbursement, some physicians have decided to opt out of the Medicare program formally. These physicians still can treat Medicare beneficiaries; they simply render services under a private contract and do not bill Medicare. These physicians certainly could order services or refer patients for services. Additionally, there is a complicating factor: opt-out physicians and practitioners are allowed to treat Medicare beneficiaries and bill Medicare if the services are for urgent⁽³⁾ or emergent conditions.⁽⁴⁾

⁽¹⁾MMA 2003, that is, the Medicare Modernization Act, had a provision indicating that when CMS issued a proposed Federal Register, it had to be published within three years. Otherwise CMS would have to start over on the national public rulemaking process.

⁽²⁾The most recent call was held on Oct. 27, 2011. The transcript, without questions and answers, is available at http://www.cms.gov/ProspMedicareFeeSvcPmtGen/downloads/Transcript_102711_Revalidation_Call.pdf.

⁽³⁾While not widely recognized, CMS developing the 12-hour rule definition for urgent conditions was prompted by allowing opt-out physicians to treat both urgent and emergent conditions. See the Nov. 2, 1998 Federal Register, page 58902 (63 FR 58902).

⁽⁴⁾For further information on opt-out physician/practitioners, see CMS Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, § 40.