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2017 Medicare Physician Fee Schedule Final Rule Impacts Providers and Suppliers in Medicare Advantage Networks

Dennis G. Sadler \ 05-24-17

+ Medicare

A stitch in time saves nine.” – popularized by Benjamin Franklin in his “Poor Richard’s Almanac”

Medicare Advantage Plans, sometimes called “Part C” or “MA,” are plans offered by private companies, under which enrollees still have Medicare. However, the enrollees get Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from the MA, and not Medicare. Medicare then pays the private companies to cover the Medicare benefits.

Under provisions of the 2017 Medicare Physician Fee Schedule Final Rule (Final Rule), providers and suppliers in Medicare Advantage (MA) organization networks and certain other designated plans are now required to be enrolled in Medicare in an “approved status.” You may be surprised that this was not a requirement before now, and the Centers for Medicare & Medicaid Services (CMS) advises that a large percentage of MA providers and suppliers are already enrolled in Medicare. However, while there are a relatively small number of providers and suppliers affected by this rule, those who are providing services to MA enrollees should immediately ensure that they are enrolled in Medicare to continue to provide those services.

Moreover, CMS has made it clear that, providers and suppliers must be enrolled in Medicare in an “approved status.” Merely having submitted an enrollment application alone is not sufficient to comply with the Final Rule. Rather, to be enrolled in an “approved status” the enrollment process must be completed. Further, a provider or supplier who has been deactivated because of a lack of claims submission is not considered to be in an “approved status.” Rather, such providers or suppliers must reactivate their enrollment by contacting their Medicare Administrative Contractor (MAC) and following the reactivation procedures.

Any provider or supplier who anticipates that they will provide services to MA enrollees should confirm their status in Medicare. This is especially true for those who may have only accepted MA enrollees without accepting Medicare in the past, or those who may have previously been approved, but have not recently submitted Medicare claims. As CMS points out, this will be a relatively small number of providers and suppliers. Nevertheless, that will be little comfort if you are among the unfortunate group of providers or suppliers who fail to obtain “approved status” from Medicare before providing services to MA enrollees. Making the small effort now to confirm your status with Medicare could may save untold problems later. In this instance, there is much more to be saved than a few stitches.

Dennis Sadler received a J.D. from the University of Memphis, Cecil C. Humphreys School of Law and an L.L.M. in Health Law, with a Concentration in Compliance, from Loyola University, Chicago School of Law. He is a Member of the law firm of Leitner, Williams, Dooley & Napolitan, where his practice focuses on health law, construction law, products liability, premises liability, and auto liability.