Got Medicare Billing Privileges? Are You Sure? Traps for the Unwary in Medicare Enrollment

by Buchalter

Buchalter Nemer Points & Authorities, Spring 2014

To receive payment for items and services furnished to Medicare beneficiaries, a health care professional or facility must have approved Medicare billing privileges, which requires enrollment in the Medicare program. Failure to update or apply for Medicare enrollment in a timely fashion, or comply with other rules governing Medicare billing privileges, risks the complete denial of claims for payment. This article highlights a few fundamentals of Medicare enrollment, which may help health care professionals and facilities avoid a few simple mistakes and their potentially extreme consequences. 

First, some definitions within the Medicare program:

  • a “provider” furnishes patient care services for those who are awaiting, receiving, or recuperating from treatment rendered by intervening practitioners. Providers include hospitals, hospices, home health agencies and skilled nursing facilities. 
  • a “supplier” furnishes the goods and services that actually comprise patient care and treatment, e.g., physicians, physician group practices, other health care professionals, ambulatory surgery centers and portable x-ray units. 

Trap: Physicians, certain non-physician practitioners and group practices have thirty days to notify the Medicare administrative contractor (“MAC”) about a change in practice location. Missing the deadline will preclude payment for services rendered more than thirty days prior to the effective date of the updated Medicare enrollment.

When a Medicare-participating physician group practice hires a new physician or a non-physician practitioner (an “NPP”), i.e., a nurse practitioner, clinical nurse specialist, certified mid-wife or physician assistant, the group practice must ensure that Medicare enrollment for the new hire is properly linked to the group at the practice location where he or she will provide services.  For example, if the group hires a physician who is already enrolled in the Medicare program, but is enrolled at the location of the physician’s former employer, the physician must submit a complete Medicare enrollment application indicating the new employer’s practice location. The complete application package must be submitted within thirty days of commencing services at the new location.  42 C.F.R. § 424.516(d)(1)(iii).

Specifically, the new hire will have to submit a Center for Medicare and Medicaid Services (“CMS”) Form 855I initial application and Form 855R to reassign his or her Medicare benefits to the new employer. Alternatively, the physician can use the internet-based Provider Enrollment, Chain and Ownership System (“PECOS”) located at

The effective date of Medicare enrollment for physicians, NPP’s and organizations comprised of physicians and NPP’s is the date when the enrollment application is initially filed, if that application is subsequently approved by the MAC, or the date when the supplier first began furnishing services at the newly enrolled practice location, whichever is later. § 424.520(d). The date of filing the application is likely to be the later of the two dates. Therefore, if the new hire completes the application process by submitting the application forms and all required supporting documentation within thirty days of his or her starting date with the new employer, the effective date of billing privileges will coincide with a date that falls within thirty days of the new hire’s commencement of services for the new employer.

The Medicare rules generally permit physicians, NPP’s and physician and NPP organizations to retrospectively bill for services rendered up to thirty days prior to the effective date of enrollment. 42 C.F.R. § 424.521(a)(1). If the effective date assigned for the new hire’s Medicare billing privileges is no more than thirty days after his or her first date of employment, the group practice will be able to bill retrospectively for all of the physician’s Medicare-covered services performed for the group, beginning with the first date of service. The same thirty-day deadline and retrospective billing opportunity applies to a physician or NPP who must enroll in the Medicare program for the first time. Missing the deadline will preclude payment for services rendered more than thirty days prior to the effective date of Medicare enrollment.

Trap: CMS may deactivate the Medicare billing privileges of a provider or supplier who fails to submit a reimbursement claim for twelve consecutive calendar months. Medicare payment will be lost for any services performed after the twelve-month period of non-billing.

CMS has the discretion to deactivate the billing privileges of a provider or supplier who fails to submit any Medicare claims for twelve consecutive calendar months. If a provider or supplier is enrolled in Medicare at multiple practice or service locations, program instructions require the MAC to deactivate the billing privileges applicable only to the non-billing location.

Medicare beneficiaries have no financial responsibility for any expense incurred by a provider or supplier for otherwise covered items and services furnished after deactivation. The attempt to collect payment from a Medicare patient may result in criminal liability. § 424.555.   

Trap: The Medicare program will not pay for certain items and services unless they are ordered by a physician or qualified NPP who is enrolled in the Medicare program

Upon receipt of a patient referral for home health services, the home health agency should confirm that the ordering physician is enrolled in Medicare. Similarly, a clinical laboratory, imaging services supplier or a supplier of durable medical equipment, prosthetics, orthotics and supplies (“DMEPOS supplier”) should check the enrollment status of the ordering physician or qualified NPP. If the National Provider Identifier shown on the reimbursement claim for the ordering physician or NPP does not correspond to an enrolled individual, the MAC will deny payment to the home health agency, clinical laboratory, imaging services supplier or DMEPOS supplier. § 424.507.

Trap: An application for Medicare enrollment may be denied if the applicant, or any owner of the applicant, has not repaid a Medicare overpayment.

Under the Medicare rules, enrollment may be denied to a physician or NPP who has not repaid a Medicare overpayment. § 424.530(a)(6). Enrollment may also be denied to any provider or supplier if the applicant’s owner has not repaid an overpayment. Implicitly, however, an applicant owner’s overpayment will impede enrollment only if the applicant has disclosed the owner in the Form 855 application. 

DISCLAIMER: Because of the generality of this update, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice based on particular situations.

© Buchalter | Attorney Advertising

Written by:


Buchalter on:

Readers' Choice 2017
Reporters on Deadline

"My best business intelligence, in one easy email…"

Your first step to building a free, personalized, morning email brief covering pertinent authors and topics on JD Supra:
Sign up using*

Already signed up? Log in here

*By using the service, you signify your acceptance of JD Supra's Privacy Policy.
Custom Email Digest
Privacy Policy (Updated: October 8, 2015):

JD Supra provides users with access to its legal industry publishing services (the "Service") through its website (the "Website") as well as through other sources. Our policies with regard to data collection and use of personal information of users of the Service, regardless of the manner in which users access the Service, and visitors to the Website are set forth in this statement ("Policy"). By using the Service, you signify your acceptance of this Policy.

Information Collection and Use by JD Supra

JD Supra collects users' names, companies, titles, e-mail address and industry. JD Supra also tracks the pages that users visit, logs IP addresses and aggregates non-personally identifiable user data and browser type. This data is gathered using cookies and other technologies.

The information and data collected is used to authenticate users and to send notifications relating to the Service, including email alerts to which users have subscribed; to manage the Service and Website, to improve the Service and to customize the user's experience. This information is also provided to the authors of the content to give them insight into their readership and help them to improve their content, so that it is most useful for our users.

JD Supra does not sell, rent or otherwise provide your details to third parties, other than to the authors of the content on JD Supra.

If you prefer not to enable cookies, you may change your browser settings to disable cookies; however, please note that rejecting cookies while visiting the Website may result in certain parts of the Website not operating correctly or as efficiently as if cookies were allowed.

Email Choice/Opt-out

Users who opt in to receive emails may choose to no longer receive e-mail updates and newsletters by selecting the "opt-out of future email" option in the email they receive from JD Supra or in their JD Supra account management screen.


JD Supra takes reasonable precautions to insure that user information is kept private. We restrict access to user information to those individuals who reasonably need access to perform their job functions, such as our third party email service, customer service personnel and technical staff. However, please note that no method of transmitting or storing data is completely secure and we cannot guarantee the security of user information. Unauthorized entry or use, hardware or software failure, and other factors may compromise the security of user information at any time.

If you have reason to believe that your interaction with us is no longer secure, you must immediately notify us of the problem by contacting us at In the unlikely event that we believe that the security of your user information in our possession or control may have been compromised, we may seek to notify you of that development and, if so, will endeavor to do so as promptly as practicable under the circumstances.

Sharing and Disclosure of Information JD Supra Collects

Except as otherwise described in this privacy statement, JD Supra will not disclose personal information to any third party unless we believe that disclosure is necessary to: (1) comply with applicable laws; (2) respond to governmental inquiries or requests; (3) comply with valid legal process; (4) protect the rights, privacy, safety or property of JD Supra, users of the Service, Website visitors or the public; (5) permit us to pursue available remedies or limit the damages that we may sustain; and (6) enforce our Terms & Conditions of Use.

In the event there is a change in the corporate structure of JD Supra such as, but not limited to, merger, consolidation, sale, liquidation or transfer of substantial assets, JD Supra may, in its sole discretion, transfer, sell or assign information collected on and through the Service to one or more affiliated or unaffiliated third parties.

Links to Other Websites

This Website and the Service may contain links to other websites. The operator of such other websites may collect information about you, including through cookies or other technologies. If you are using the Service through the Website and link to another site, you will leave the Website and this Policy will not apply to your use of and activity on those other sites. We encourage you to read the legal notices posted on those sites, including their privacy policies. We shall have no responsibility or liability for your visitation to, and the data collection and use practices of, such other sites. This Policy applies solely to the information collected in connection with your use of this Website and does not apply to any practices conducted offline or in connection with any other websites.

Changes in Our Privacy Policy

We reserve the right to change this Policy at any time. Please refer to the date at the top of this page to determine when this Policy was last revised. Any changes to our privacy policy will become effective upon posting of the revised policy on the Website. By continuing to use the Service or Website following such changes, you will be deemed to have agreed to such changes. If you do not agree with the terms of this Policy, as it may be amended from time to time, in whole or part, please do not continue using the Service or the Website.

Contacting JD Supra

If you have any questions about this privacy statement, the practices of this site, your dealings with this Web site, or if you would like to change any of the information you have provided to us, please contact us at:

- hide
*With LinkedIn, you don't need to create a separate login to manage your free JD Supra account, and we can make suggestions based on your needs and interests. We will not post anything on LinkedIn in your name. Or, sign up using your email address.