Medicare enrollment problems,Medicare payments

A 3-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, commented 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 (275-page PDF; About PDFs). 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.