In accordance with the Patient Protection and Affordable Care Act (PPACA) Section 6401, all new and existing suppliers of Durable Medical Equipment Prosthetics, Orthotics, and Supplies (DMEPOS) must be reevaluated under the new screening guidelines implemented as a result of the PPACA in the Medicare Program by no later than March 23, 2015. CMS requires DMEPOS suppliers to revalidate enrollment information with the National Supplier Clearinghouse (NSC) every three years. When suppliers receive their letter from CMS to revalidate their enrollment, the supplier has 60 days from the date of the letter to submit complete enrollment. You cannot initiate your revalidation, you must wait for your letter from CMS.
The enrollment process includes filling out the CMS 855-S application. Enrollment can be completed on-line through the Internet based Provider Enrollment, Chain and Ownership System (PECOS). On-line enrollment should be done by the authorized official of the DME supplier. To revalidate via the Internet-based PECOS, go to
However, you must submit certification documentation and other supporting documents (see page 35 of the 855-S application) by mail. These documents must be submitted within 7 days of filling out the on-line enrollment application.
Since you have to send some documents for this application via mail anyway, I suggest mailing the complete 855-S application with supporting documents to the National Supplier Clearinghouse (NSC) address on page 3 of the CMS 855-S. Send it to the street address with a return receipt request.
All suppliers responding to a revalidation request are required to submit an enrollment fee via Pay.Gov prior to submitting the application. The fee for all revalidations submitted during calendar year 2012 is $523. If you feel you qualify for a hardship exception waiver, submit a letter and financial statements to request a waiver in lieu of the enrollment fee along with your application and certification statement. Revalidations are processed only when fees have cleared or the hardship waiver has been granted.
Please review the following tips to avoid delays in processing:
a. Include a copy of all applicable federal, state licenses and certifications ( see article "Check Your Licensure Requirements")
b. Include a copy of the certificate of insurance for your comprehensive liability insurance in the amount of $300,000. The NSC must be listed as a certificate holder.
c. Include a copy of your surety bond, if applicable.
d. Ensure the certification statement is signed and dated (blue ink is recommended)
e. Remit enrollment fee via Pay.Gov and include a copy of your receipt or submit a letter and financial statements to request a hardship exception waiver.
Failure to submit a timely revalidation will result in deactivation of your billing privileges. Should this occur, it may take up to three years to reactivate them. In addition, I think that if you are a substantial biller to Medicare for Cataract Surgery, it might throw up a red flag if your optical is suddenly deactivated because you failed to do the paperwork to keep your DME Supplier status current.
Are Your Providers in PECOS?
Check to see that your referring providers are registered in PECOS (Provider Enrollment Chain and Ownership System). This would include internal and external doctors who write prescriptions for post-op cataract patients. These providers MUST appear in the CMS "Ordering Referring Report" or the dispensary will not get paid.
Be sure to correct this BEFORE you submit your revalidation paperwork.
Pamela Fritz has assisted hundreds of practices with enrollment, revalidation, billing, coding, and compliance. Contact Pam at 860-669-9057 or by email at firstname.lastname@example.org.
Important Medicare Update for Ophthalmologists, Optometrists and Opticians
Starting March 24, 2011, all DME optical suppliers (Ophthalmologists, Optometrists, and Opticians) are facing increased scrutiny of their optical dispensary's qualifications as suppliers of eyewear provided after cataract surgery. Suppliers are being evaluated regarding the standards of DME compliance as determined by DMEPOS Standards.
Why optical dispensaries? Optical suppliers are concerned that they are being singled out for scrutiny. This is not so. Recently, Medicare has been given a broad scope to examine fraud and abuse in the entire area of DMEPOS ( Durable Medical Equipment, Prosthetics, Orthotics and Supplies). Thus far, hundreds of millions of dollars have been recovered in fraud and abuse by DME Suppliers in such areas as wheelchairs, power mobility equipment, and other DME supplies. The refractive lens category does not fall high on detection of fraud and abuse, however, all DME Suppliers have now “have been thrown under the same bus” to be scrutinized.
If your practice does cataract surgery and if your optical dispensary fills eyewear prescriptions for patients after cataract surgery, Pam Fritz, of Ophthalmology Resources and Medicare reimbursement specialist strongly recommend that you maintain your eligibility as a DME supplier. Your patient’s Medicare benefits are at stake. Patients benefits after cataract surgery include a “complete pair of eyeglasses” after each surgery (some restrictions apply). If you are not a qualified DME supplier, you are required to tell your post-op cataract patients the competitors who are qualified DME suppliers. What a missed opportunity for your optical dispensary!
Medicare eyewear reimbursements after cataract surgery offer excellent insurance benefits. The patient may be eligible for two pairs of eyeglasses, one after each surgery, if they meet Medicare qualifications. Don’t let your practice miss out. Some optical chains are already geared up to take care of Medicare patients. Are they telling you something? Independent practitioner’s patients should not lose out on this important opportunity to use their benefits at their doctor’s office.
Become DME Medicare compliant now. After March 25, 2011, non-compliant optical dispensaries face a $500 enrollment charge (per dispensary location) for each new enrollment or dispensary reactivation or re-enrollment. These applications will also face increased scrutiny by DME Medicare and you still may not qualify to become a DME supplier. You can avoid this by taking action NOW.
How do I know if my Optical Dispensary(s) may not be DME Supplier Compliant?
Do you have any of the following issues:
If you answered "YES" to any of the above, immediate action is required to protect your DME Supplier Status.
Compliance Webinars Being Planned Now
If you are interested participating in a free webinar by Pam Fritz on how to be in compliance before the deadline, log on to our POF Newsletter site and check the box for Medicare Update Webinar. We will inform you of the times and dates the webinar will be presented. Click here to submit your e-mail for information.
CMS offers Physicians/Practitioners Special Opportunity to Participate
By Pamela B Fritz
Usually the opportunity to change your status from non-participating provider to participating provider occurs once per year, from November through December 31. Due to the recent enactment of the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010, CMS is offering physicians and other practitioners (optometrists) a special opportunity to become participating (PAR). This is only for physicians/practitioners whose current PAR status is non-participating. Announced on June 28, 2010 the opportunity is available only through July 16, 2010.
If you wish to become a participating provider, download and complete the Medicare Participating Physician or Supplier Agreement (Form CMS-460) from their website: http://www.cms.gov/cmsforms/downloads/cms460.pdf
Any new CMS-460 form received during this limited enrollment period will be retroactive for claims with dates of service Jan 1, 2010 and after. However, this will only apply to new claims received after your status as a PAR provider is processed. Remember, your CMS-460 form to become a participating provider must be post-marked on or before July 16, 2010.
PECOS Deadline Approaching
Act Now - Prevent Payment Interruption
Now is the time to make sure your ordering/referring providers are enrolled in Medicare's Internet based PECOS (Provider Enrollment Chain and Ownership System). The deadline for compliancy is Jan 3, 2011.
To find out if your physician and non-physician (optometrist) provider's information is in PECOS, review the list released by CMS of physician and non-physician providers who are eligible to order and refer in the Medicare program. The list is alphabetical with the first and last name and NPI. Suppliers can access the list at https://www.cms.gov/Medicare/Provider
Click "Ordering/Referring Report" to view the list. Suppliers should check to see if their internal and external, "outside" referring providers are listed. If your internal providers are not listed, the provider will have to update their information in PECOS. As a Supplier, you cannot do this for the provider unless the provider has authorized you through CMS. If an outside referring providers is not listed in PECOS, you should contact them and let them know that you will be unable to fill the Rx's of their referred post-op cataract patients until they update their PECOS enrollment. Contacting outside referring providers can be a sensitive issue. Several of the DME MAC contractors have a sample letter for contacting outside providers which you can modify to fit your needs. Search "PECOS" at your DME contractor's website.
NHIC MAC A: www.medicarenhic.com
Noridian MAC D: www.noridianmedicare.com
NGS MAC B: www.ngsgovernmentservices.com
CIGNA MAC C: www.cignagovernmentservices.com
After Jan 3, 2011 the DME supplier's claims with ineligible referring providers will be denied. Claims filed electronically will receive notification of the denial. Paper claims will not be paid and no notification will be issued.
Top 6 DME Supplier Registration Mistakes
Resulting in Claim Denials
1. The optical dispensary does not have it's own NPI (National Provider Identifier). The optical is the DME Supplier, not the practitioner or the group practice. The optical usually should be registered as its own organization with a separate NPI.
2. A PTAN (also referred to as Medicare supplier number or Legacy number) is not linked to your NPI. Your PTAN must appear in the NPI Registry (https://nppes.cms.hhs.gov/) with your NPI information under the "Other Provider Identifier" section in order for your NPI to crosswalk to your Medicare supplier number or PTAN.
3. Your PTAN has lapsed. CMS requires that DME Suppliers renew their PTAN numbers every
three years. Many DME Suppliers have mistakenly thought that with the advent of NPI’s, keeping their DME Supplier number (PTAN) current was not necessary. If your DME Supplier Number/PTAN has lapsed, you will need to re-activate or re-enroll with NSC (National Supplier Clearinghouse)
4. You optical does not have a Surety Bond. With few exceptions, most DME Optical Suppliers need a Surety
5. The name of the Optical DME Supplier provided in the NPI Registry and the TIN (tax identification number) provided do not match. The exact name of your optical as reported to the IRS must be used in the NPI registry.
6. If you have multiple DME Optical Supplier locations, each location MUST have a separate PTAN (Medicare NSC Supplier number) and a separate NPI.
Surety Bond for DME Optical Dispensary Suppliers
By Pamela B Fritz
While initial directives from CMS (Centers for Medicare and Medicaid Services) seemed to indicate that physicians who provided eyewear(eyeglasses & contact lenses) to their post-op cataract patients were exempt from the requirements of a surety bond, clarifications have proven otherwise.
The National Supplier Clearinghouse (NSC) has issued guidance that interpreted the statutory language from the Federal Register (January 2, 2009, 42 CFR Part 424.57 (c) (26) and 424.57(d), “All existing DMEPOS suppliers subject to the bonding requirements shall submit a copy of the required surety bond to the NSC no later than October 2, 2009”. The NSC guidance’s contradict CMS’ indications that persons receiving post-cataract eyewear are considered the ophthalmologist’s patients, regardless of whether or not they had cataract surgery performed by that practice.
It is important to note that these guidelines apply whether or not you are a participating DME provider. All Durable Medical Equipment (DME) Suppliers must conform to the Medicare DMEPOS Supplier Standards in order to retain their billing privileges. For a copy of the 26 supplier standards (short version) go to www.palmetto.gba.com You can download both the long or short versions at this site.
What to do If CMS contacts you about a Surety Bond.
Starting November 9, 2009, CMS began contacting DME Suppliers who had not submitted proof of a surety bond to NSC. Letters were sent to physicians, optometrists and opticians who appeared to be non-compliant because they did not submit proof of their surety bond and did not appear to meet the exemptions.
The letter states that, “your Medicare supplier number…..will be revoked effective 30 days from the postmark of this letter”. It further indicated,”The supplier is barred from re-enrolling in the Medicare program for one (1) year from the effective date of revocation”.
If you receive a letter from CMS, the first thing to do is make sure that your optical does indeed require a surety bond. If you fall under the previously listed requirements, then you most likely need a surety bond. Remember, you will need a surety bond for each optical location if that location is a DME Supplier (with NPI and DME PTAN). Many practices make the mistake of dispensing post-op eyewear to their patients at another one of their optical locations that does not have an NPI or PTAN. The practice may think the billing can be generated from another one of their locations that has the PTAN and NPI. This is incorrect and will cause claim rejection.
If you have already acquired a surety bond before the October 2, 2009 deadline, then you should immediately email NSC: NSC.REVOCATIONS@palmettogba.com. You must send them proof that you acquired a surety bond before the Oct 2, 2009 deadline.
If you acquired the surety bond after the deadline you must go through the procedure of submitting a CAP (Corrective Action Plan), along with proof of your surety bond within 30 days of the postmark of the CMS letter.
Surety Bond Requirements for PTAN and NPI
If you have not acquired a surety bond and need to do so here is the process to get started.
You should contact one of the sureties identified on the U.S. Department of Treasury’s listing: www.fms.treas.gov/c570/c570_a-z.html. Pam Fritz has worked with LSJ Insurance (www.lsjins.com) to secure surety bonds. These sureties are considered “authorized” sureties and are therefore the only sureties from which a bond may be obtained.
All surety bond insurance companies will require you to have a valid NPI (National Provider Enumerator) number and DME Supplier number (PTAN). Be sure that these numbers are current.
You must have a separate organizational NPI for your optical. Check the Registry (nppes.com) to see that the proper taxonomy code is used for “Eyewear Supplier” and that your PTAN number is entered in “Other Provider Information”.
Regarding your DME Supplier number (PTAN), check to see if it is current by contacting NSC. You will need your login and password information to access your DME Supplier account. Also, go on-line to see if you are properly registered in the DME Supplier Directory (www.medicare.gov). Search “Supplier Directory”
Surety Bond Application Tips
Surety Bond company owner, Samir Jallad of LSJ Insurance indicates that these are the most common mistakes made on surety bond applications:
Once the surety bond application is completed processing is usually very quick. Upon receipt of the surety bond, it is important that the rest of the application process be completed as quickly as possible in order to meet CMS’s 30 day response requirement. The surety bond information must be accompanied by a CAP (Corrective Action Plan). This is a letter, on the applicant’s optical letterhead, signed by the authorized official. It should indicate that this is a “Corrective Action Plan” and state that the applicant meets all of the requirements of the “DME Supplier Standards” which now include the surety bond requirement. A copy of the surety bond documentation must be included. Mail this paperwork to: National Suppliers Clearinghouse, PO Box 100142, Columbia, SC 29202-3142 ATTN: Hearings and Appeals.
NSC advises that you should allow “2 weeks for your submission documentation to show-up in the NSC”. That’s why expediting your paperwork as soon as you are contacted by CMS is so critical. It is hoped that your postmarked CAP received by NSC within 30 days of their original letter will qualify to meet their deadline requirements, regardless of how long the paperwork processing takes at NSC.
If you do not meet the 30 day requirement, you still have a 60 day window to appeal the revocation decision. In this case, you must submit both a CAP and “reconsideration”. The reconsideration process will however require your presentation of your case before an “independent hearing officer” from CMS.
If you do not follow up on the revocation letter with a CAP or reconsideration, or if you do not receive a favorable decision on your appeal, you must wait one (1) full year before resubmitting a CMS 855s application to be considered for re-enrollment as a DME Supplier.
POF Special Update
From POF September 2010 Focal Point Newsletter
$50K Surety Bond Requirement for Medicare Billing Privileges
We are very concerned and appalled as you are, that opticians were not one of the professions exempted from having to provide proof of a $50,000 surety bond in order to maintain their Medicare billing privileges.
Five South Florida locations Delray to Stuart
Link to contacts outside of Florida
For purposes of the surety bond requirement, these sureties are considered "authorized" sureties, and are therefore the only sureties from which a bond may be obtained.
Coordinated by the Opticians Association of America. we will be providing you a simple and direct way to communicate with your member of Congress about this vital issue.
Stay tuned for updates and how you can be involved.
Medicare Surety Bond Summary
Provided by the OAA
DMEPOS Surety Bond & Accreditation Requirement for Medicare Billing Privileges
Per final regulations implemented by CMS, DMEPOS suppliers will be required to become accredited to obtain and maintain Medicare billing privileges by October 1st of this year, others may be required to post a surety bond by October 2nd to secure Medicare billing privileges and most will be required to provide both.
For additional information regarding DMEPOS accreditation or the provisions associated with a surety bond, go to this web site .
Frequently Asked Questions (FAQs) on the surety bond requirement can be found on the NSC's FAQ page.
WEBINAR PRESENTATION PRINTOUT
"How to Fast Track Your Optical Dispensary to be a DME Compliant Supplier for Post-op Cataract Eyewear" presented by Pamela FritzMedical Health Insurance Claim Form 1500
Subscribe to Pamela Fritz's Medicare DME Supplier Newsletter
What You Need to Know
When You Need to Know It
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Update on Meeting The Deadline
If you are required to get a Surety Bond and fail to do so, your optical dispensary will have its Medicare supplier number suspended and your claims for post-cataract eyeglasses will not be paid. You will be required to re-apply for a new supplier number, and any post-cataract eyeglasses dispensed until that number is issued cannot be billed to Medicare by you or by the patient.
Updates provided by: Pamela B Fritz is President of Ophthalmology Resources, LLC She serves on the Provider Outreach & Education Advisory Panels of the Medicare Durable Medical Equipment Contractors that cover the Northeast, Mid-West and Western U.S.
Q. How and to what address do I send bond paperwork to the NSC?
A. The applicable bond paperwork should be submitted along with: (1) Section 12 of the 03/09 version of the CMS-855S and (2) a signed and dated certification statement from that application. Links to those forms are listed below (A cover letter that explains the purpose of the submission is suggested, but not required.) If the supplier has multiple locations, it may submit one set of bond paperwork, one certification statement, etc., encompassing all of its locations. The address to which the bond and associated CMS-855S paperwork should be sent is as follows:
Q: How does an optometrist or ophthalmologist who dispenses eyeglasses qualify for the physician exemption?