CMS’ New Regulations on Ordering and Referring Physicians

As a result of enhanced program integrity provisions of the Affordable Care Act, the Centers for Medicare and Medicaid have been developing new regulations governing the chain of services provided to Medicare and Medicaid beneficiaries. On January 6, 2014, new regulations governing the Medicare and Medicaid enrollment of ordering and referring physicians began to go into effect. Under these new regulations, Medicare and all state Medicaid programs are required to begin screening and enrolling ordering and referring physicians (“ORPs”) in their Medicare and Medicaid programs prior to reimbursing for any services provided.

In sum, if the ORP was not previously enrolled as a provider in Medicare or a state Medicaid program for their own claims submissions, the ORP will need to enroll as an ORP provider to continue ordering or referring Medicare or Medicaid beneficiaries for services. Though the regulations have already gone into effect, many MACs and state Medicaid programs have given providers a grace period of varying lengths. Those grace periods are beginning to run out, and many MACs and states have already begun denying claims based on noncompliance with these regulations.

When reviewing claims for imaging services, CMS has instructed MACs and state Medicaid programs to look for the following three requirements: (1) the ORP’s NPI – which must be for the individual physician or non-physician provider that ordered or referred the services; (2) the ORP must be enrolled in Medicare or Medicaid; and (3) the physician or non-physician provider must be of a specialty type that is eligible to order or refer for those services. Claims that do not satisfy all three requirements will be denied.

Break Away from the Static

This requirement becomes problematic for radiologists submitting claims for their radiology services for two reasons: (1) it threatens a radiologist’s ability to receive timely reimbursement for their properly performed services; and (2) it is the requirement of the radiologist – as the entity submitting the claim to Medicare or Medicaid for reimbursement – to provide the NPI of the ORP on the claim in order to receive payment. CMS’ regulations unfairly punish the radiologists, as the party seeking reimbursement from Medicare or the state Medicaid program for non-compliance by ORP’s.

In relation to the claims process, CMS originally stated that it would not deny the claims that did not satisfy the requirements, but CMS has now indicated that the claims will be denied. The regulations do provide full appeal rights to the suppliers. In relation to the enrollment status of the ORP, the ORP is required to be enrolled in Medicare or the state Medicaid program prior to the date of service. Even if the ORP’s enrollment status is pending, the claim will be denied. Additionally, if an ORP is enrolled with Medicaid in one state, but refers a patient for radiology services in a second state, the ORP must be enrolled with the second state’s Medicaid program in order for the radiologist to be reimbursed.

ORPs can become enrolled with Medicare via the CMS-855O application, available on CMS’ website, as well as through the PECOS system. ORPs can enroll with state Medicaid programs by accessing that particular state’s Medicaid website. Prior to enrollment, ORPs must obtain a type 1 NPI from the National Plan and Provider Enumeration System, located on the CMS website.

As always, ADVOCATE will keep you updated on this and other issues impacting radiology as they become available.

Best regards,
Julia Leo
Chief Compliance Officer