SCMS News Briefs - JULY 2008

Deadline to submit resolutions to the 2008 House of Delegates is August 5

The most effective way an individual CMA/SCMS member can influence CMA's policies and activities is to submit resolutions to the House of Delegates, the association's legislative body. The delegates meet annually to debate and act on resolutions and reports dealing with the myriad medical practice, public health and CMA governance issues.

The deadline to submit a resolution for this year's House (October 3-5 in Sacramento) is August 5. Any CMA member may author a resolution, but a delegate or alternate delegate must submit the resolution.

Before authoring a resolution, physicians are strongly encouraged to review CMA's Policy Compendium (available at CMA's members only website), to determine whether policy already exists on a particular topic.

Resolutions must be submitted by email to resolutions@cmanet.org by August 5. For more information on submitting a resolution, contact the medical society at solanomedsoc@sbcglobal.net or by phone at 707 425-7267. Detailed instructions are available at www.cmanet.org/member.

Beware of Board Certification Schemes

Many physicians may remember the days before California law prohibited physicians from advertising of "board certification" from an unrecognized medical specialty. In 1993, a state law took effect that allowed physicians to advertise board certification ONLY if the certifying board or association is recognized by the American Board of Medical Specialties (ABMS) or deemed to be equivalent by the Medical Board of California (MBC). Before the law took effect, physicians were bombarded regularly with advertisements for quick and easy "board certification" programs. Occasionally such advertisements still show up on the Internet or in physician mailboxes, tempting the unwary.

CMA recently became aware of a certification program offered by the American Board of Diabetes, an organization that is not recognized by the ABMS or deem equivalent by the MBC. According to the advertising materials, physicians can become "board certified" by paying $300, filling out a two-page application, and paying annual dues of $25.

While physicians are certainly free to pay $300 for a certificate, state law prohibits advertising that certification unless the certifying organization is recognized by the ABMS or MBC. (The only non-ABMS boards currently deemed equivalent by the MBC are the American Board of Cosmetic Surgery, the American Board of Facial Plastic and Reconstructive Surgery, the American Board of Pain Medicine, the American Board of Sleep Medicine, and the American Board of Spine Surgery.)

Physicians are encouraged to research any such organization before handing over their cash. The American Board of Diabetes website, for example, indicates that its "evangelical mission" is the "humanitarian crusade of the congregation of religious medical ministries and the humanitarian crusade against the ongoing murders of poor street children in Latin America."

More details are available in the CMA ON-CALL document #0205, "Advertising by Physicians." All ON-CALL documents are free of charge to CMA/SCMS members at http://www.cmanet.org/member. Non-members pay $2 per page through the CMA Bookstore.

Guidance for Physicians Experience NPI Related Claims Rejection

In Brief
The Centers for Medicare and Medicaid Services (CMS) is requiring Medicare carriers to deny claims in cases where it cannot internally match a physician’s Medicare Provider Identification Number (PIN) with his or her National Provider Identification (NPI) number. CMS has begun validating claims that contain both a legacy number and a NPI number against a central database known as the National Provider Identifier (NPI) Crosswalk, which contains NPI numbers and legacy numbers that physicians provided as part of the process in obtaining their NPI with the National Plan and Provider Enumeration System (NPPES). If the NPI/PIN combination on your claim does not match the NPI/PIN combination on the claim does not match the NPI/PIN combination in the NPI Crosswalk, your claim will reject.

Physicians experience claims denials should review their denial messages and contact Medicare to determine the reason for the denials so that the appropriate action can be taken to correct the problem. The reasons for these denials include solo incorporated physicians not having “group” Medicare PIN numbers to match to their “organization” NPI numbers on claims forms, among others. The NCMS, CMA and AMA have protested CMS’ punitive approach to denying claims when most of these problems are attributable to Medicare’s internal claims processing. CMS has nonetheless remained unwilling to stop denying claims but has offered assurances that CMS staff and staff at the Medicare fiscal intermediary will provide direct assistance to those affected physicians. NCMS members who are unable to get such assistance should contact the NCMS office at 255-3622.

Past Medicare Enrollment Practices May Have Contributed to Problem
One reason a claim will reject is if the NPI and PIN are used in combination on the claim does not identify the same entity. For example, the NPI in the “Billing Provider” field might be the corporation’s NPI, but the PIN used in combination with it might be the physician’s PIN. Because the entity types differ - organization NPI with individual PIN - Medicare will reject the claim. This pairing may be the result of variations in past Medicare enrollment and PIN assignment procedures. For example Medicare carriers may have combined the enrollment of a physician and his/her corporation into a single enrollment; or, a sole proprietorship may have been enrolled as a corporation because the sole proprietorship was issued as Employer Identification Number (EIN) by the IRS. These and similar situations may require physicians who are experiencing claims rejections to ensure their Medicare enrollment information, and that of their corporations (if they are incorporated), is correct.

Physician Practitioner Who Are Incorporated
Corporations include professional corporations, most limited liability companies, professional associations, and partnerships. Generally, the corporations that physicians/practitioners form are referred to as groups or group practices. Corporations include solo incorporated group practices. Corporations include solo incorporated physicians but do not include solo proprietorships. When you are billing Medicare through your corporation, both you and your corporation must enroll in Medicare.

If you are a physician who has established a corporation, you must obtain an NPI for yourself and an NPI for your corporation. A corporation applies for an NPI as an Entity Type 2 (Organization) and you apply for an NPI as an Entity Type 1 (Individual). If you, or your corporation, is not enrolled in Medicare, and you use the NPI of the non-enrolled entity in combination with the PIN of the enrolled entity (or vice versa), you will encounter claims problems because the combination is incompatible and will not be found in the Medicare NPI Crosswalk. If the corporation will be billing Medicare, it may use only its NPI (once it has one), only its PIN (once it has one), or its NPI/PIN in combination (once it has both) would be used to identify you - the physician - as the Rendering Provider. Until the enrollment application of the nonenrolled entity can be processed, you may want to use only the PIN or only the NPI of the enrolled entity to avoid claims processing problems.

Physicians/Practitioners Who Have Side Proprietorships
A sole proprietorship is a business whereby all of the business’s assets and liabilities are tied directly to the physician’s (the sole proprietor’s) Social Security account. The sole proprietor and the sole proprietorship are considered a single legal entity: an individual. The sole proprietor’s Social Security Number (SSN) serves as the Taxpayer’s Identification Number (TIN) of the sole proprietorship. Often, the Internal Revenue Service (IRS) issues an Employer Identification Number (EIN) to a sole proprietorship to protect the sole proprietor’s SSN from being disclosed on W-2s and in transactions, such as claims to health plans. Therefore, an option of the sole proprietor, the EIN (if issued) instead of an SSN could be used as the TIN in submitting a sole proprietorship’s Medicare claims. The IRS links that EIN to the sole proprietor’s SSN for tax reporting purposes. You/your sole proprietorship must be enrolled in Medicare.

If you are a physician who has a sole proprietorship, you must obtain an NPI for yourself as an Entity Type 1 (individual). There is no separate NPI for the sole proprietorship. When you/your sole proprietorship are billing Medicare, you may use only your NPI (once you have one), only your PIN (once you have one), only your PIN (once you have one), or your NPI and PIN in combination (once you have both) to identify yourself as the Billing/Pay-to-Provider and as the Rendering Provider.
Physician/Practitioners Who Have No Private Practice
You must be enrolled in Medicare in order for the services you render to Medicare beneficiaries to be reimbursed by the Medicare program. If you do not have a sole proprietorship and have not formed a corporation, you do not bill Medicare directly; instead, you reassign your benefits to another entity, usually a group or group practice, and the group or group practice bills Medicare for the services that you perform. That group or group practice must also be enrolled in Medicare, but you are not responsible for enrollment fo the group or group practice. The group or group practice would submit claims in which you could be identified as a Rendering Provider.

You must obtain an NPI for yourself as an Entity Type 1 (Individual). The group would be responsible for ensuring that you are appropriately identified in the group’s claims; that is, the group would ensure that your NPI (once you have one) is used with the compatible PIN (your PIN, once you have one) if using the NPI/PIN combination; or, the group may use only your NPI (once you have one) or only your PIN (once you have one) to identify you as the Rendering Provider. The group must have it own NPI and would use only the NPI (the group’s NPI, once it has one), only the PIN (the group’s PIN, once it has one), or the NPI (the group’s NPI once it has one) with the compatible PIN (the group’s PIN, once it has one) in combination to identify itself as the Billing Pay-to-Provider.

If Your Claims Are Rejected
1. Check Medicare Reject Report messages.

2. If you use billing companies, clearinghouses, and administrative staff, check to find out if they have been contacted by the Medicare carriers concerning problems in matching the NPI/PIN combinations to the Medicare NPI crosswalk.

3. Check your information ( and that of your corporation, if you formed one) in the NPPES to ensure that the NPI (s) were properly obtained. For example, if you have a sole proprietorship, you should have an individual PIN and you should have obtained an NPI as an Individual (Entity Type 1), not as an Organization (Entity Type 2).

4. Ensure that the NPPES data (for you and your corporation, if you formed one) are correct, and that the NPPES record (s) contains the Medicare legacy identifier (s) that was assigned to the provider (physician or the corporation) to whom the NPPES record belongs. For example, a physician applying for an NPI would list his/her Medicare PIN in the “Other Provider Identifiers” section of the NPI application, but would not list the PIN of the group in which he/she is a member. Medicare uses this information in building the Medicare NPI crosswalk in incorrect reporting will flow into the NPI crosswalk and cause problems down the road. To view or edit your NPPES record, go to https://nppes.cms.hhs.gov on the CMS website. For assistance, call the NPI Enumerator at 800-465-3202.

5. If the NPI(s) was properly obtained and the NPPES information is correct and you continue to get information NPI edits: Ensure that your (and your corporation’s, if you formed one) Medicare enrollment information is up to date. If the carrier asks that you or your corporation re-enroll or update the enrollment information, ensure that a complete application is submitted (CMS 8551 and, if appropriate, CMS-855R). When completing the CMS-8551 or CMS-855R, list your NPI and the NPI of the corporation (group practice) to which benefits will be reassigned (if applicable) in the appropriate places on the CMS-8551 and, if the CMS -855R is necessary, on the CMS-855R. Be sure to also

ist the NPI and the PIN of the corporation (group practice) in the appropriate places on the CMS-8551 and, if the CMS-855R is necessary, on the CMS-855R (if PINs have been assigned). The Medicare document referenced earlier will assist you in doing this. Also, make sure that the Medicare enrollment record reflects the correct Taxpayer Identification Number (TIN) for use by Medicare in reporting your income to the IRS on the 1099 form. For example, if you are an incorporated physician, your Medicare payments need to be associated with your corporation’s TIN and not your SSN. If the enrollment record does not reflect this, a CMS-8551 must be completed in order to update it.

NPI Database Available to Look-Up Referring/Ordering Physicians and Facilities.

Members are reminded that as part of the NPI requirement, physicians must include the NPIs of referring physicians and health care facilities on their claim forms. CMS has established online listing of NPI numbers for physicians and organizations to look up the NPIs at https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do.

Further Resources
All physicians, including sole proprietorships and incorporated physicians, applying for enrollment in Medicare must have the appropriate NPI(s) and must report NPIs on the CMS-855 Medicare Provider Enrollment Application. Physicians must also report the NPI(s) of the corporations, sole proprietorships, groups, or group practices to which they will be reassigning their benefits. Further information on enrollment scenarios is now available at http://www.cms.hhs.gov/Medicareprovidersupenroll/Downloads/EnrollmentNPI.pdf on the CMS website. General Medicare Enrollment information can be found at http://www.cms.hhs.gov/MediareProviderSupEnroll on the CMS website.