The Centers for Medicare & Medicaid Services (CMS) continued its efforts to increase oversight of the Medicare program by updating Medicare provider enrollment regulations. Specifically, updates have been made to Medicare’s provider and supplier enrollment regulations at 42 C.F.R. §424, Subpart P, effective January 1, 2024. This regulatory update included several changes, however, there are two noteworthy updates that effect DMEPOS Suppliers, a new middle ground called a stay of enrollment and a reclassification of revocation reasons.
Stay of Enrollment
The first of these was the creation of a new Medicare provider enrollment action, the Stay of Enrollment. CMS describes a stay of enrollment as a CMS action that’s less burdensome on providers and suppliers than a deactivation or revocation of your Medicare enrollment. A stay of enrollment (or “stay”) is a preliminary, interim status representing a pause in enrollment.
In a CMS MLN Matters article (MM13449) released this month, it is explained that a stay of enrollment is a two-step process in which 1) the provider is non-compliant with at least one Medicare enrollment requirement that 2) could be remedied by submitting the appropriate CMS Form, to include the 855 enrollment application or 588 EFT authorization agreement. If the non-compliance cannot be remedied by the submission of one of the listed CMS forms, then a stay of enrollment cannot be imposed. The article includes some examples of situations in which a stay of enrollment may be imposed, including:
- Failing to timely report a change in address from 10 Smith Street to 20 Smith Street
- Non-response to a revalidation request
- Failure to report the deletion of a managing employee
In these examples, the provider failed to adhere to a reporting, revalidation, or supplier standard requirement, but could resume compliance by submitting the appropriate CMS form.
Key Points of a Stay
- You remain enrolled in Medicare during the stay
- Your MAC will reject claims you submit with dates of service within the stay period
- Your stay of enrollment lasts no longer than 60 days
- CMS can impose a stay of less than 60 days
- A stay ends on the earlier of the following dates:
- The date on which we or your contractor decides you resume compliance with all Medicare enrollment requirements
- The day after the imposed stay period expires
- A stay isn’t considered an adverse legal action of any kind
- CMS may impose a stay multiple times for separate instances of non-compliance, for example, a stay in June 2024 and another stay in December 2025
How do I know if I’m eligible for a Stay?
If you are eligible for a stay of enrollment, your MAC will send all stay notification letters by hard-copy mail and e-mail, if a valid email address is available. They’ll also send the notice via fax if a valid fax number is available. MACs will mail all notification letters on the same date listed on the letter.
What do I do if I’m notified of a Stay?
You may file a rebuttal under a stay of enrollment. A rebuttal is an opportunity for you to show you met all applicable enrollment requirements and that the stay shouldn’t have been imposed. You may submit only one rebuttal request per enrollment stay.
If the supplier submits the appropriate form for the stay while a rebuttal submission is pending or during the rebuttal submission timeframe, the MAC will process the form consistent with current instructions.
National Provider Enrollment (NPE) and DME MAC Interaction
The NPEs and the DME MACs will interact, coordinate, and communicate with each other in stay situations consistent with our instructions. For example:
- The NPE will notify the DME MAC of the imposed stay or when the stay has been lifted, as well as any subsequent deactivation
- Upon being informed of a stay by the NPE, the DME MAC will withhold payment for services provided during the stay period
New and revised Medicare Denial and Revocation Authorities
42 C.F.R. § 424.535(a) defines the reasons that a Revocation of enrollment in the Medicare program may occur. CMS may revoke a currently enrolled provider or supplier's Medicare enrollment and any corresponding provider agreement or supplier agreement for the reasons provided under §424.535(a)(1) – (23).
When a revocation occurs, a supplier’s billing privileges are terminated and they are subject to a re-enrollment bar that establishes a time period in which they must wait before they can reenroll in the Medicare program. The reenrollment bar begins 30 days after CMS or its contractor mails notice of the revocation and lasts a minimum of one year, but not greater than 10 years depending on the severity of the basis for revocation.
A revocation can be resolved with the submission of a Corrective Action Plan (CAP) or Reconsideration, depending on the reason for revocation. Prior to the changes effective January 1 of this year, most revocations fell under 42 CFR 424.525(a)(1) for noncompliance and allowed submission of a Corrective Action Plan to resolve reasons for revocation. 42 C.F.R. §424.535(a)(1) states “The provider or supplier has violated an enrollment requirement listed on the application it/he/she uses for enrollment purposes”. Examples of these enrollment violations included but were not limited to the following:
- Expired or missing licensure
- Expired or lapsed insurance
- Expired, cancelled or changes to surety bond coverage
- Expired or failed accreditation
- Changes of information that were not reported timely (30 days)
Essentially, if a provider or supplier was determined to be noncompliant with DMEPOS Supplier Standards a CAP was afforded to resolve the issue(s) and reinstate billing privileges.
With the changes CMS implemented, the revocation reasons have since be reclassified and a violation of DMEPOS Supplier Standards is no longer considered noncompliance. Instead, revocation reason 23 (42 CFR § 424.535(a)(23)) has been added, which is defined as a Standard or Condition Violation, and lists the following as it pertains to DMEPOS in subsection (ii): The DMEPOS supplier is non-compliant with any provision in § 424.57(c).
And guess what provisions are listed in § 424.57(c)…DMEPOS Supplier Standards. Which means that if a supplier receives a revocation notice that cites § 424.535(a)(23), the only recourse is to submit a Reconsideration. By CMS definition, a reconsideration is “An opportunity for a provider/supplier to furnish evidence that demonstrates that there was an error made at the time of the initial determination affecting participation in the Medicare Program”.
Under this new revocation authority, if a supplier changes their surety bond coverage and fails to notify the National Provider Enrollment Contractor (NPE) of the new bond information and the prior bond on file was expired, then a reconsideration would not be an available course of action. Why? Because at the time the NPE made the determination, the surety bond on file had expired. In this example, the DMEPOS supplier would be revoked from Medicare and would be under a one-year re-enrollment bar.
The same revocation authority under § 424.535(a)(23) would apply if the supplier fails to update their enrollment file for licensure or insurance, or any other change that is required to be reported within thirty days. If the information was not up to date when the violation was discovered by the NPE, a CAP would not be allowed.
The van Halem Group is a member of both the DME MAC and NPE Advisory Councils, and I can report that council members have been communicating to CMS the severity these changes could have on our industry. CMS has acknowledged our concerns and has explained that there will be changes in the guidance provided to the NPE contractors so that suppliers do not find themselves terminated from the program with a minimum of one year re-enrollment bar. At this time, no timeframe has been shared by CMS as to when this instruction could change. This means that if you receive a revocation notice it is imperative that you review the reason cited under § 424.535(a). If the revocation lists noncompliance under (a)(1), then CAP rights are afforded. However, if the revocation letter cites (a)(23), the supplier can only submit a reconsideration.
Keeping your PTAN safe
It is important for DMEPOS suppliers to understand that managing enrollment and licensure is an element of compliance. Suppliers need to be proactive. Waiting for the NPE contractor to identify expired licenses or missing information on your enrollment file will result in a revocation. It is recommended that you develop a system internally that will allow you to manage and track licenses and important due dates. This can be done simply, with the creation of a spreadsheet and calendar notifications.
And should you be on the receiving end of a revocation notice, contact us! Our experts can assist with Corrective Action Plans and Reconsideration responses. We also can provide enrollment support and maintenance to ensure changes made on your enrollment file are correct and result in little to no development from the NPE.
And as previously mentioned, the van Halem Group will continue to stay abreast of any changes made by CMS related to the newly implemented revocation guidance. More importantly, we honor our commitment to share this information with members of the DMEPOS industry as we learn more. Be sure to subscribe to our blog so that you will be notified the minute we hear more!