Medicare Enrollment Process Fraught With Opportunities for Missteps

AAFP Offers Tips on Problem Avoidance, Resolution

June 04, 2010 04:55 pm Sheri Porter

A three-physician, family medicine practice in Lexington, Va., recently found itself with roughly $40,000 in unpaid Medicare claims -- practice revenue that was in limbo because of a cascade of blunders in Medicare's physician enrollment process.

Brenda Harlow, office manager for Lexington Family Practice since 1981 and, thus, no newcomer to the Medicare game, said she'd never seen anything like the mess in which the practice found itself recently.

The nightmare started with the completion of Medicare enrollment forms in January. A series of events, including Medicare contractor mailroom mishaps and a lack of clarity about what information the contractor needed from the practice, stretched on for nearly two months, according to Harlow.

Then the hammer came down.

"Payments from Medicare were stopped on March 12," said Harlow. Subsequently, the practice was notified that, as of May 25, all three physicians in the practice could be "barred from Medicare for a year."

Robert Pickral, M.D., has been serving Medicare patients at the Lexington practice since 1981. "What is the message to the physicians of America when this kind of disruption happens?" he asked.

"We operate a small practice in a small community. Revenue is way down, and federal quarterly taxes are due," said Pickral, adding that Medicare patients account for nearly 25 percent of the practice's patient panel.

As of June 2, the practice still had no resolution regarding the Medicare enrollment problems, and it still has not received any Medicare payments.

According to Kent Moore, the AAFP's manager of health care financing and delivery systems, there is no way to know for sure how many other Academy members are experiencing similar problems with Medicare. But "I do know that Pickral's practice is not alone," he said.

"I have exchanged e-mails and phone calls with other AAFP members who have run afoul of Medicare's physician enrollment process," said Moore, adding "in some cases, physicians have had their Medicare billing privileges revoked as a consequence."

Avoiding Medicare Mishaps

Medicare's Provider Enrollment, Chain and Ownership System, or PECOS, may be the source of many problems, including those experienced by Pickral's practice, according to Cynthia Hughes, C.P.C., an AAFP coding expert who works with Moore in the AAFP's Practice Support Division.

The Internet-based PECOS was established in 2003, and physicians who have not submitted an enrollment application since it went operational need to re-enroll, said Hughes.

She also cited physician revalidation rules laid out in the Medicare Program Integrity Manual( According to the manual, Medicare providers and suppliers "must resubmit and recertify the accuracy of their enrollment information every five years in order to maintain Medicare billing privileges."

According to Hughes and Moore, physicians can be proactive to prevent problems with Medicare. For example, physicians should

  • log in to PECOS to see if they are registered there and to ensure that their information is complete and accurate;
  • respond to Medicare requests for revalidation of enrollment in a timely manner, so if issues crop up, there is ample time to resolve them; and
  • report any provider changes, such as a change of address, promptly.

"Physicians may think Medicare is picking on them, but the real issue is that there are lots of new rules that everyone is trying to follow," said Hughes.

She suggested that physicians who are rushing to beat a Medicare enrollment deadline and who are not already established in PECOS should submit a paper application. "Approval for PECOS registration can take some time," said Hughes.

Ironing Out Problematic Issues

Despite a physician or office manager's best efforts, however, problems may occur that need immediate attention. When that happens, Moore recommended that physicians first try to resolve the matter with their local Medicare contractor.

"The person making that call could be a billing person or a skilled practice manager, but whoever it is needs to understand Medicare's enrollment process before he or she has that conversation," said Moore.

If help isn't forthcoming at the contractor level, the next step is a phone call to the practice's CMS regional office.( The states covered in each of the 10 regions are listed on CMS' website. (See box for names and contact information.)

CMS Regional Offices

Contact information for the associate regional administrator for Financial Management and Fee for Service Operations for each of CMS' 10 regional offices is listed below.
• Region 1, Boston: Thomas Grannemann
(617) 565-1331
• Region 2, New York: Peter Reisman
(212) 616-2500
• Region 3, Philadelphia: Charlotte Foster
(215) 861-4140
• Region 4, Atlanta: Dale Kendrick
(404) 562-7347
• Region 5, Chicago: Gregory Dill
(312) 353-9841
• Region 6, Dallas: Jimmy Sigmund
(214) 767-6441
• Region 7, Kansas City, Mo.: Lisa Goschen
(816) 426-5033
• Region 8, Denver: Lisa Goschen
(816) 426-5033
• Region 9, San Francisco: Eileen Turner
(415) 744-3654
• Region 10, Seattle: Mal White
(206) 615-2331

According to Moore, "nine times out of 10, the regional office can sort out the problem between the contractor and the physician because the regional office can hold a stick over the contractor."

Whoever makes that phone call, however, needs to have all pertinent documents at hand that outline any previous communication with CMS, said Moore. "Get the name, e-mail and phone number of everyone you talk to, and try to talk to the same person each time you call," said Moore. Use that information to create a paper trail, he advised.

If a family physician practice still is having problems, Moore encourages the practice to contact him at the AAFP. "Physicians are free to call me for help after working through their regional office," he said.

"If physicians don't complete the Medicare enrollment form correctly, things can snowball quickly," said Hughes. "We'd rather walk members through some instructions upfront than try to untangle a mess at the back end of the process."