The Medicare Problem Your Eye Care Practice Doesn’t Need

Enrolling in the Medicare program can be such an arduous and paperwork-laden process that once you’re in, you may think (or more likely, hope) you’re set for life. Not so. Some eye care providers are finding themselves unexpectedly deactivated from Medicare, prompting missed reimbursements, denied claims, and staff time and energy spent on reactivating enrollment.

Reactivation “has kind of been the thing that sneaks up and bites us,” says Linda R. Georgian, COE, who spoke about Medicare enrollment at the 2018 ASCRS·ASOA Annual Meeting last April. Nobody likes to work for free, but that’s essentially what you’re doing when you’re treating patients while deactivated, she explains. To find out how to avoid deactivations and learn what you need to do to get back on track, chew on these quick tips.

Know Your Numbers

When it comes to Medicare, you have two numbers to keep track of: National Provider Identifiers (NPIs) and Provider Transaction Access Numbers (PTANS). A physician will have only one NPI, and it is portable should he or she practice at multiple locations. The practice itself will have one or more NPIs, depending. In contrast, PTANs are issued by each individual MAC, and it’s possible for a physician to have more than one (say, if a practice has a satellite office in a different payment locality than the main office). PTANs are not portable—they do not follow the physician. If a provider joins a new practice, he or she must apply for a new PTAN.

Identify Deactivation Cause

One reason that some physicians see deactivations is because they haven’t treated Medicare patients recently enough, says Georgian. You can be deactivated if you have not submitted any Medicare claims for four consecutive quarters. You may think this isn’t likely in an ophthalmology practice, but it can happen, Georgian warns. She gives this example:

Say an ophthalmologist was set to join a new practice, He was ready to go, and the staff had obtained the necessary PTAN. But then, he had a change of heart and stayed with his original practice. Eventually, he came around, moved to the new practice, and started treating patients. But since four quarters had passed between enrollment and submitting a claim, the physician was no longer active in the system. His claims would be denied.

Another reason for deactivation is that the practice is going through revalidation but doesn’t fill out the documents correctly or answer requests quickly enough to meet the MAC’s deadline. If too much time has passed, these providers can be deactivated from Medicare. Applications take 60-180 days to process Georgian reports. And if you have a physician coming from another state? Don’t get excited, she warns. The application will take the same amount of time as a brand new doctor coming into the Medicare system.

Take Revalidation Notices Seriously

Medicare requires you to revalidate your enrollment every five years. If you receive a revalidation notice from your MAC, you should take it seriously and complete the steps required in it—ASAP.

Once you start the enrollment/revalidation process, physicians can technically treat Medicare patients and just hold those claims and submit them once the process is complete, Georgian notes. But that’s risky. If there’s something wrong with the application and it gets denied, you can’t bill for the patients you started treating, since the physician was deactivated at the time, Georgian explains. You’ve just treated all those patients for free.

So how bad can it get? Georgian points to one example of a physician who had to take out a $250,000 loan to keep her practice open following revalidation issues. Many times, the doctor isn’t even aware of the issue and continues to see patients as if nothing is happening. “That’s how disastrous this is,” Georgian said. “I’ve seen people lose their jobs over this.”

Make Sure Your Timing is Right

You’ll typically receive a revalidation notice two or three months prior to its due date, so when yours arrives, don’t waste any time. Some of the processes may be time-consuming and you don’t want to miss out on reimbursements if your staff is delayed in completing the required fields. If you make a mistake on the application, you’ll have to restart the process, and if you don’t meet the deadline, you’ll face deactivation.

In fact, it’s a good idea to determine NPI and PTAN expiration dates in advance. By the time you receive the notice, you’ll be in a time crunch to complete the process. Knowing those dates can give you a head start. But at the same time, don’t get too far ahead. “Don’t submit your revalidation applications more than six months prior to the due date,” Georgian advises.

Another reason to know your dates? Some physicians report that they never even see a revalidation notice before they experience deactivation. That can stem from the MAC sending the notice to the physician’s former practice so he or she never realizes that revalidation was due. Notices are sent to the correspondence address on file with CMS, and those can go years without being updated.

Eyes Open: Optical is different. If your practice has multiple locations and an optical, you must have an NPI for each location. You’ll also need to revalidate every three years instead of every five.

Know That Medicare Is Boosting Enforcement

Wondering why you’ve suddenly heard about more practices experiencing revalidation issues and deactivations? Truth is, the deadlines aren’t new. It’s just that until now, CMS has been somewhat lenient in enforcing them—but that’s ending, notes Georgian. Medicare contractors have indicated that they’re going to start enforcing the due dates in revalidation notices. They’re not even going to give that 30-day grace period like they used to, she warns. “They’re playing a really hard line here.”

If your physician works at multiple locations, make sure you select one person to do the revalidation. Then, ensure that they follow through on all of the steps. Assuming that someone at the doctor’s other location is handling the revalidation can be dangerous, since they might be assuming your location is taking care of it.