Many billers and administrative staff are well versed in claim denials related to things like missing or inappropriate modifiers, medical necessity, or even referring physician PECOS enrollment. One area that billers rarely anticipate is a claim denial that is directly related to the practice’s DMEPOS Supplier Enrollment application. These denials, although seemingly less common, can be more time-consuming to navigate and have significant financial implications.
One common misconception related to enrollment is regarding businesses that have expanded into multiple locations that are all linked to the same Tax Identification Number (TIN). Despite the commonality of the TIN, each location needs to be separately enrolled with Medicare and have its own Provider Transaction Access Number (PTAN) and National Provider Identifier (NPI). As separately enrolled locations, the claims must be separate as well. If a device is delivered out of Location A, the claim must be billed with the PTAN/NPI for Location A. Billing a claim that was delivered at one location with a PTAN/NPI for a different location is inappropriate and could jeopardize your Medicare enrollment status.1
Another common issue related to enrollment and claim submission is the product categories offered by each of the locations. Any time a location adds or removes a product category from its offering, Medicare enrollment must be updated to reflect this change. As an example, for any supplier that added lymphedema compression garment to its list of offered products when the benefit category was added to the Medicare program in January 2024, it would have had to report this change by updating its 855S Medicare enrollment form on the PECOS website.2 Failure to accurately report products/services to Medicare could result in denied claims.
Another commonly overlooked requirement for DMEPOS Supplier Enrollment is the surety bond. It is not uncommon for small O&P clinics to be eligible for an exemption from having to secure a surety bond (i.e., solely owned/operated by O&P personnel, and it only provides orthotics, prosthetics, and supplies). However, what is forgotten is the fact that this exception must be reported on the Medicare 855S enrollment form.
We bring these concerns to your attention as a cautionary tale. Suppliers just like you, with no ill intention, have overlooked these seemingly minor details concerning their Medicare enrollment and are at risk. Such mistakes can result in temporary deactivation of billing privileges or, in more serious and egregious cases, permanent revocation. These results could have a serious monetary impact on the overall health and well-being of the business. Now is the perfect time to review your DMEPOS Supplier Enrollment to ensure everything is current and accurate to prevent any unexpected surprises for your billing team.
Lesleigh Sisson, CFo, CFm, and Curt Bertram, CPO, are part of the leadership team at O&P Insight. Sisson and Bertram have a combined 64 years of experience in O&P administration, clinical services, and operational management. You can contact them at [email protected] or [email protected]. Michelle Wullstein, CPCO, has been in the Medicare profession for over 18 years and is an AAPC certified professional compliance officer and provides O&P specific medical policy, billing, documentation, and HIPAA compliance support to internal teams and clients. While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors.
References:
- https://www.palmettogba.com/palmetto/npewest.nsf/DIDC/CHEQ6K7311~Articles
- https://pecos.cms.hhs.gov/pecos/login.do#headingLv1
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