Let me say from the outset, that no one should
ever be dissuaded from contacting their
Congressional delegation about what they perceive
as an unfair practice by CMS or any
other Federal agency. That being said, the times
are much different now than they were
prior to the President’s State of The Union
Address this past winter. Also Dr. Smith and
Name Withheld DO NOT have the same scenario!
Having spent almost a decade on the DME Medicare
Council, meeting with the NPE program directors, I
am happy to provide some insight into their
thinking and what is going on at CMS. I too have
also been a victim of having my Medicare number
stolen and having had numerous DME billed under
my MCR number, which I both never received and
never needed. So I support the Federal
Government’s initiative to combat DME fraud (which
is rampant).
With the war on Medicare fraud taking on many new
fronts, even your local Congressional
representative may now be at a loss to assist you.
In fact, they may be supportive of the initiatives
to fight DME fraud. This because RFK and CMS have
made it a point to bite off the head of the snake
on Medicare fraud, as their belief is that it all
stems from the enrollment programs. Some have said
that it is easier to become rich by committing
white collar DME fraud than becoming involved in
other criminal activities.
Dr. Smith in his comments, suggested that there
were some forms that may not have been completed
correctly and not responded to in a timely manner.
That would today result in a Stay in Enrolment,
where one’s PTAN is temporarily suspended but not
deactivated. That is you are not banished from the
Medicare program but also not allowed to be paid
until your issues were resolved. In this situation
Medicare would contact you. If in Dr. Smith’s
case, the office did not respond, you may
ultimately have your PTAN revoked.
Name Withheld situation appears to be somewhat
different because according to their
PM News letter, their practice manager “failed to
renew their Medicare enrollment/revalidation:”
That is not a minor but a major difference from
Dr. Smith’s issue(s).
If you don’t respond, Medicare may think you are
no longer in business, moved from that location
without notifying them or a criminal enterprise.
On the other hand, one may claim that they never
received notice of re-enrolment (that
is the letter was lost in the mail). One may also
ask why in this digital world is the NPE
relying on USPS?
The reason given is that you are legally obligated
to report any address change to the NPE. Also you
are legally obligated to keep tract on when your
re-enrollment is up (see more on this later).
Because so many people change their email address,
the CMS agencies would be flooded with change
requests and hence CMS agencies refuse to be
legally obligated to send applications to email
addresses. Faxing notices? Well faxes are going to
be the next horse and buggy and CMS is doing away
with fax notifications of any sort.
Prior to the new war on fraud, knowing and working
with the NPE enrollment teams, I was able to
persuade them to bend a bit and allow several
practitioners back into the system. One was able
to recover over $100K.
However two other practices were not so lucky and
are now out quite a bit of outstanding revenue
plus the cost of the DME. Since you are legally
obligated to know when your enrollment is up for
renewal, it is your practice which must take an
active part in the re-enrollment process. There
are backup processes that your practice must
adhere to.
The primary one is that there should never be one
person who has sole access to the keys of the
store. This includes the scenario where an outside
agency does your credentialing as I have heard
stories of where the outside agency drops the ball
and now the DME supplier is banned for two years.
A back up plan is mandatory. Employees get injured
or sick, leave for a variety of reasons, etc.
Hence a backup plan to who has the “keys of the
store” is a necessity. The alternate could be the
physician owner or physician practice manager as
the alternate.
Hard or digital copies of your last enrollment
application should be easily accessible.
Last, not knowing when your PTAN is up for renewal
is inexcusable. For local Medicare it is typically
five years. For DME it is every three years. Each
individual office must have its own PTAN. There is
NO, I repeat no fee for your physician PTAN for
local Medicare. For DME the fee is now about $750
per location payable every three years. For
$250/year you are going to place significant
revenue at stake and face accusations under the
False Claims Act?
Random inspections do happen. Lie on your
application and you can be slapped with charges
under the False Claims Act. One orthopedist is
currently wearing an orange jump suit for the next
decade for lying on a DME application as well as
having to pay restitution.
In closing I have several suggestions:
1) Medicare renewal is no joke and must be taken
very seriously!
2) Use an outside person well versed in the
application process to review or submit
your DME (and local Medicare) applications. These
have become too complicated for most office
personnel and physicians to complete. Too much is
stake if your PTAN is deactivated. The fees paid
for a competent person submitting your application
pale in comparison to what you may lose. This is
no place to take shortcuts.
3) Have a backup plan for the loss of a key
employee.
4) You can check whether your PTAN is up for
renewal by going to:
https://data.cms.gov/tools/medicare-revalidation-
list
This works for both your local and DME PTAN. If
you have multiple locations,
you should check each PTAN for each location. Keep
a database of this information easily accessible
by multiple employees and routinely check on this.
It will tell you up to six months in advance
whether or not you are up for renewal. You
are not obligated to respond 90 days in advance.
5) Failure to obtain a PTAN in each location where
you dispense DME, can result in banishment from
the Medicare program for several years. All it
takes is one employee to ask the inspector at one
office “When are you coming to our other
location(s)? This happened to one of my clients
who tried to save a few hundred dollars a year.
Guess what, they are now out hundreds of thousands
of dollars. They also have to answer that question
on every insurance application: Have you
ever been terminated from a Federally funded
insurance program?
Paul Kesselman, DPM, Oceanside, NY
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