Summary
Despite the recent debate in the U.S. Supreme Court regarding the constitutionality of the health care reform act, CMS published a final rule related to several provisions from the Affordable Care Act (the "Act").
On April 27, 2012, the Centers for Medicare & Medicaid Services (CMS) issued a final rule (the "Final Rule") requiring all Medicare and Medicaid providers and suppliers of medical services that qualify for a National Provider Identifier (NPI) to include their NPI on all applications to enroll in the programs and on all claims for payment submitted under the programs. The rule can be retrieved at http://www.gpo.gov/fdsys/pkg/FR-2012-04-27/pdf/2012-9994.pdf.
An NPI is a unique identification number that health care providers are required to include on all standard electronic transactions, such as electronic claims, eligibility verifications, claims status inquiries and/or claim attachments. CMS mandated the adoption of NPIs to improve the efficiency and effectiveness of the electronic transmission of health information. The preamble to the Final Rule notes, "To maintain program integrity and ensure quality, [CMS] must make certain that only qualified providers and suppliers participate in the programs and that they bill accurately for these services."
The Final Rule makes several modifications to the CMS interim final rule published on May 5, 2010. The Effective Date of the Final Rule is June 26, 2012.
Medicare and Medicaid Enrollment Applications
The Final Rule amends 42 CFR §424.506 and requires new Medicare enrollees to report their NPI on their enrollment forms. Providers and suppliers that enrolled in Medicare before obtaining an NPI may update their enrollment records by submitting Form CMS-855 or the Internet-based PECOS application. Physicians who have opted out of Medicare are not required to update their enrollment applications.
Although there is no federally required "enrollment application" for the Medicaid program, Medicaid providers must enter into a provider agreement with their respective states as a condition of participating in the Medicaid program. CMS is therefore including the submission of an NPI to any state agency as a requirement under the Medicaid provider agreement. Medicaid participants with current provider agreements may include their NPIs during the next date of revalidation.
Ordering and Referring Covered Items and Services
The Final Rule requires that claims for Part A and Part B home health services and Part B DMEPOS items and services contain the NPI of the physician or eligible professional that ordered or referred the item or service. Medicare contractors may deny claims that do not include a provider or supplier's NPI.
Maintaining the integrity of participants in the Medicare and Medicaid program is an important element of the Act and the Final Rule. CMS projects that the total savings resulting from the Final Rule will be approximately $1.59 billion over the next 10 years. The Final Rule demonstrates the intersection of policy and fiscal considerations that are affecting each element in the health care delivery system.
