Medicare Physician Revalidation Extended Two Years to March 2015 and a Sample Revalidation Letter

The Centers for Medicare & Medicaid Services (CMS) has extended the revalidation period for another 2 years.  This will allow for a smoother process for provider and contractors.  Revalidation notices will now be sent through March of 2015.
IMPORTANT: This does not affect those providers which have already received a revalidation notice.  If you have received a revalidation notice from your contractor, respond to the request by completing the application either through internet-based PECOS or completing the appropriate 855 application form.

The first set of revalidation notices went to providers who are billing, but are not currently in the Provider Enrollment, Chain and Ownership System (PECOS).  To identify these providers, contractors searched their local systems and if a Provider Transaction Access Number (PTAN) for a physician was not in PECOS, a revalidation request for that physician was sent.  CMS asks all providers who receive a request for revalidation to respond to that request.

For providers NOT in PECOS – the revalidation letter will be sent to the special payments or primary practice address because CMS doesn’t have a correspondence address.  For providers in PECOS – the revalidation letter will be sent to the special payments and correspondence addresses simultaneously; if these are the same it will also be mailed to the primary practice address.  If you believe you are not in PECOS and have not yet received a revalidation letter, contact your Medicare contractor.  Contact information may be found here.

Institutional providers (i.e., all providers except physicians, non-physician practitioners, physician group practices and non-physician practitioner group practices) must submit the application fee with their revalidation.  In mid-September, CMS revised the revalidation letter that contractors sent to providers to clarify who must pay the fee.

CMS plans to post a list of providers who were sent requests to revalidate.  They will make an announcement via CMS listservs when this information is posted.

See sample revalidation letter below.








Dear Provider/Supplier Name:

In accordance with the Patient Protection and Affordable Care Act, Section 6401 (a), all new and existing providers must be reevaluated under the new screening guidelines in Section 6028.    Medicare requires all enrolled providers & suppliers to revalidate enrollment information every five years (reference 42 CFR § 424.57(e)). To ensure compliance with these requirements, existing regulations at 42 CFR § 424.515(d) provide that CMS is permitted to conduct off-cycle revalidations for certain program integrity purposes. Upon the CMS request to revalidate its enrollment, the provider/supplier has 60 days from the date of this letter to submit complete enrollment information using one of the following methods:
Providers and suppliers can enroll in the Medicare program using either the:

(1) Internet-based Provider Enrollment, Chain, and Ownership System (PECOS).
To revalidate via the Internet-based PECOS, go to https://pecos.cms.hhs.gov. This system allows you to review information currently on file, update and submit your revalidation via the internet. Once submitted, be sure to print, sign, date, and mail the certification statement along with all required supporting documentation. In order for us to process the revalidation, the original signature and documentation must be received within 15 days of internet submission.

Physicians and non-physician practitioners will access Internet-based PECOS with the same User ID and password that they use for NPPES. For assistance in establishing an NPPES User ID and password, or if you have forgotten your ID or password or wish to change your NPPES password, contact the NPI Enumerator at 1-800-465-3203 or TTY 1- 800-692-2326, or send an e-mail to customerservice@npienumerator.com

For provider/supplier organizations, your Authorized Official must register with the PECOS Identification and Authentication system. If you have not registered, do so now by going to (https://pecos.cms.hhs.gov). This registration process can take up to three (3)weeks. If additional time is required to complete the revalidation, you may request one 60-day extension, which will begin on the date of the request.

To avoid any registration issues, review the internet-based PECOS related documents available on the CMS Web site (www.cms.hhs.gov/MedicareProviderSupEnroll).

(2) Paper Application Process
To revalidate by paper, download the appropriate and current CMS-855 Medicare Enrollment application from the CMS Web site at www.cms.hhs.gov/cmsforms. Mail your completed application and all required supporting documentation to the [insert contractor name], at the address below.

[Insert application return address]

With the exception of physicians, non-physicians practitioners, physician group practices and non-group practices, providers and suppliers that are revalidating their enrollment information must submit with their application an application fee.

The 2011 application fee of $505 or a request for hardship exception must be included with the provider enrollment application. Submit the enrollment fee via Pay.Gov prior to submitting the application (reference 42 CFR 424.514). You can submit your application fee by electronic check, debit or credit card. If you feel you qualify for a hardship exception waiver, submit a letter and financial statements to request a waiver in lieu of the enrollment fee along with your application or certification statement. Revalidations are processed only when fees have cleared or the hardship waiver has been granted. You will be notified by mail if your waiver request has been granted or if a fee is required.

For more information on the application fees and other screening requirements under the PPACA view the MLN Matters Article at http://www.cms.gov/MLNMattersArticles/downloads/MM7350.pdf.

You are required by regulations found at 42 CFR 424.516 to submit updates and changes to your enrollment information in accordance with specified timeframes. Reportable changes include, but are not limited to changes in: (1) legal business name (LBN)/tax identification number (TIN), (2) practice location, (3) ownership, (4) authorized/delegated officials, (5) changes in payment information such as changes in electronic funds transfer information and (6) final adverse legal actions, including felony convictions, license suspensions or revocations of a health care license, an exclusion or debarment from participation in Federal or State health care program, or a Medicare revocation by a different Medicare contractor.

Failure to submit complete enrollment application(s) and all supporting documentation within 60 calendar days of the postmark date of this letter may result in your Medicare billing privileges being deactivated.

If you have any questions regarding this letter, please call [contractor telephone number will be inserted here] between the hours of [contractor telephone hours will be inserted here] or visit our Web site at [insert Web site] for additional information regarding the enrollment process or the [insert application type].

My Notes on the March 22, 2011 CMS Open Door Forum on Physician Quality Reporting System (PQRI) for the Beginner

Very scary

Today’s CMS Open Door Forum was a good one. The slides (pdf here), although reviewed quickly during the call, are a comprehensive resource for anyone needing in-depth information on qualifying for incentives through PQRI. The information is complex, but anyone can start the process tomorrow and successfully get their check (next year.)

PQRI has been renamed PQRS.

These are the key points of the information presented:

  1. You can tell if you are eligible for the incentive program by checking the main PQRS site here. Scroll down to Downloads and click on “List of Eligible Professionals.”
  2. There is no registration required to report quality data.
  3. PQRS should not be confused with incentives offered for ePrescribing or meaningful use of a certified Electronic Health Record – these are three distinct systems.
  4. There are new Physician Quality Reporting Measure Specifications every year – use the correct year.
  5. Reporting can be done as individual eligible providers or as groups, however groups needed to be self-nominated by January 31, 2011, so that door is closed for this year.
  6. Eligible providers can choose to report for 12 months: January 1”“December 31, 2011 or for 6 months: July 1-December 31, 2011 (claims and registry-based reporting only.)
  7. There are two reporting methods for submission of measures groups that involve a patient sample selection: 30-patient sample method and 50% patient sample method. An “intent G-code” must be submitted for either method to initiate intent to report measures groups via claims. If a patient selected for inclusion in the 30-patient sample did not receive all the quality actions and that patient returns at a subsequent encounter, QDC(s) may be added (where applicable) to the subsequent claim to indicate that the quality action was performed during the reporting period.
    Physician Quality Reporting analysis will consider all QDCs submitted across multiple claims for patients included in the 30-patient samples.
  8. Eligible professionals who have contracted with Medicare Advantage (MA) health plans should not include their MA patients in claims-based reporting of measures groups using the 30 unique patient sample method. Only Medicare Part B FFS patients (primary and secondary coverage including Railroad Medicare) should be included in claims-based reporting of measures groups.
  9. Choose which group measures OR individual measures (3 minimum) you want to report on based on your method of reporting. Review your choices here.
  10. If you plan to report using a registry or EHR, make sure the systems are qualified by checking here.
  11. Here is the schedule for PQRS incentives and “payment adjustments” (financial dings.)
  • Incentives (based on the eligible professional’s or group’s estimated total Medicare Part B PFS allowed charges)
    • 2007 ”“1.5% subject to a cap
    • 2008 ”“1.5%
    • 2009, 2010  ”“2.0%
    • 2011 ”“1%
    • 2012, 2013, 2014 ”“0.5%
  • Payment Adjustments (you lose money)
    • 2015 ”“98.5%
    • 2016 and subsequent years ”“98.0%

What follows are the Questions and Answers from the listeners.

Q: Do PQRS measures need to be reported once per encounter or once per episode?

A: It depends on the measure. Check the list to see what each measure requires.

Q: Is there a code to submit if we cannot qualify due to low numbers of Medicare patients?

A: No, CMS will calculate this and will know you cannot qualify and you will be exempt from the payment adjustment.

Q: Can both admitting physicians and consulting physicians submit the same quality codes?

A: Yes, all eligible providers working with a patient can report the same code if appropriate.

Q: How do we know if we qualified for the eRx incentive for 2010?

A: Payments will come early fall and feedback reports will be available that break down each provider’s incentive.

Q: For the eRx incentive, is it 10 eRxs before June 30, 2011 and 25 before January 31, 2011 for each PROVIDER or each PRACTICE?

A: Each provider.

Q: What is the difference between the numerator and the denominator in PQRS?

A: The numerator is the clinical quality action (for instance, putting a patient on a beta blocker) and the denominator is the group of patients for whom the quality action applies (which patients with appropriate diagnoses are eligible for beta blocker therapy.)

Q: Do all the preventive measures in this group have to be utilized?

A: Not all measures will apply to all patients, for instance mammograms for females only.

Q: Is there a code to be placed on the claim that says a measure is not applicable for this patient?

A: No.

Q: How do you know if a measure code on a claim has been accepted?

A: You will receive a rejection code on your EOB that indicates the code was submitted for information purposes only. Remittance Advice (RA) with denial code N365 is your indication that Physician Quality Reporting codes were passed into the National Claims History (NCH) file for use in calculating incentive eligibility.

Q: How can a new provider get started with quality reporting?

A: Any provider can start any time by reporting through claims, a registry or an EHR.

Q: Should providers bill for PQRI under their individual number or under their group number?

A: Under their individual number.

Q: Can a physician delegate the eRx process to a staff member, just as they might have a nurse write a prescription for them?

A: Yes.

Q: Can you clarify the three incentive programs and which a practice can participate in at the same time?

A: The Physician Quality Reporting System, eRx Incentive Program, and EHR Incentive Program are three distinctly separate CMS programs.

The Physician Quality Reporting System incentive can be received regardless of an eligible professional’s participation in the other programs.

There are three ways to participate in the EHR Incentive Program: through Medicare, Medicare Advantage, or Medicaid.

If participating in the EHR Incentive Program through the Medicaid option, eligible professionals are able to also receive the eRx incentive.

If participating in the Medicare or Medicare Advantage options for the EHR Incentive Program, eligible professionals can still report the eRx measure but are only eligible to receive one incentive payment. Eligible professionals successfully participating in both programs will receive the EHR incentive.

Eligible professionals should continue to report the eRx measure in 2011 even if their practice is also participating in the Medicare or Medicare Advantage EHR Incentive Program because claims data for the first six months of 2011 will be analyzed to determine if a 2012 eRx Payment Adjustment will apply to the eligible professional.

If an eligible professional successfully generates and reports electronically prescribing 25 times (at least 10 of which are in the first 6 months of 2011 and submitted via claims to CMS) for eRx measure denominator eligible services, (s)he would also be exempt from the 2013 eRx payment adjustment.

The transcript and a recording of today’s call will be posted on the CMS website within a few weeks.

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