Medicare Provider Number

All posts tagged Medicare Provider Number

Opt Out of Medicare: What Physicians & Practitioners Need to Know

by admin on May 14, 2018 No comments

opt out of medicareBy: Susan St. John

Physicians and practitioners are ordinarily required to submit claims on behalf of Medicare beneficiaries when payment may be made for items and services provided by the physician or practitioner. However, in today’s health care environment, more and more physicians and practitioners are considering opting out of Medicare. For those professionals facing this decision, there are a few things to consider.

Is the Physician or Practitioner Eligible to Opt-Out?

First, determine if you are eligible to opt out of providing services to Medicare patients. Not every physician or practitioner is eligible to opt out of Medicare. For purposes of opting out of Medicare, “physician” is limited to: doctors of medicine; doctors of osteopathy; doctors of dental surgery or medicine; podiatrists; and optometrists; licensed by the state in which they practice (this could be multiple states).  The term practitioner, for opt-out purposes, is limited to: PAs, ARNPs, Clinical Nurse Specialists, CRNAs, Certified Nurse Midwife, Clinical Psychologist, Clinical Social Worker, Registered Dietitian and Nutrition Professional. What is omitted from the definition of physician and practitioner are chiropractors, and physician therapists and occupational therapists in independent practice. Consequently, a chiropractor may not opt out of Medicare; neither may PTs or OTs in independent practice, but it seems PTs or OTs working in a physician’s office may be eligible to opt out.

read more
adminOpt Out of Medicare: What Physicians & Practitioners Need to Know

A Medicare Provider Reminder From CMS and OIG: Report Your CHOW

by admin on April 19, 2018 No comments

medicare providerBy: Matthew Fischer

Due to financial and regulatory constraints, many companies are merging or purchasing other healthcare companies.  However, prior to closing any transaction, these companies need to first determine whether government agencies must be provided advance notice of the change of ownership (CHOW). As an example, if Medicare is involved, these companies might be required to report the CHOW.

This issue is not one to dismiss or ignore because if companies fail to comply, they face significant penalties.  In a recent “MLN Connects” newsletter, the Centers for Medicare & Medicaid Services (CMS) issued a reminder to report changes in ownership.  The newsletter cites to an Office of Inspector General (OIG) report from 2016 that found a substantial amount of ownership changes were not being reported. 

read more
adminA Medicare Provider Reminder From CMS and OIG: Report Your CHOW

Medicare Liability (and more) Buyer Beware

by admin on May 4, 2016 No comments

By: Jeff Cohen

Healthcare businesses are bought and sold every day!  Though sophisticated people are fully aware of the risk difference between an entity sale and an asset sale, some do not understand the lingering nature of Medicare related liability.

When a legal entity (company, limited liability company, whatever) is bought, the liabilities of that entity are often assumed by the buyer.  This is because buyers that purchase selling healthcare entities like the idea of keeping both term managed care agreements and the Medicare provider number intact.  Keeping them intact can help ensure continual cash flow of the seller, but will also create Medicare liability to the buyer. 

read more
adminMedicare Liability (and more) Buyer Beware

Super Group Doctors Beware of Departure Provisions

by admin on May 18, 2012 No comments

 Super groups are in vogue as physicians do their best to reduce costs and enhance revenues.  A “super group” is essentially a collection of previously separate competitors who have joined a single legal entity in order to achieve certain advantages.  Those advantages tend to be (1) reducing overhead expense associated with economies of scale.  Buying insurance for a group of 100 doctors should be far less expensive per doctor than a group of three doctors; (2) gaining leverage in managed care contracting.  20 groups of five physicians each cannot contract with a payer with “one voice” due to the antitrust restrictions, but a single group of 100 doctors can; and (3) finding new revenue sources.  Small groups and solo practices cannot afford revenue producing services like surgery centers, imaging services and such.   When practices combine, they have a greater patient base, which makes the development of new revenue sources feasible.

Physicians join super groups with terrific promise and hope.  They are clearly a good idea, especially if they have solid operations.  That said, physicians who rush to form them rarely consider the risks associated with a physician departing the group.  They need to!

When a doctor joins a super group, she stops billing through her old practice (the “P.A.”) and starts billing through a new group (the “LLC”).  The LLC has a tax ID number and a Medicare group number.  And the LLC enters into lots of managed care payer agreements.  Simply put, the doctor puts all of her eggs in the LLC basket.  So what’s the risk?

When physicians depart super groups, they have to confront difficult facts, like:

  1. It will take months to get a new Medicare provider number.  If they haven’t billed through their “old entity” for a while, that number is gone.  And getting a new number for the departing physician takes time, during which revenues associated with Medicare patients are lost (until the number is obtained);
  1. It takes even longer to get on insurance plans.  If the LLC is contracted (they usually are), how long will it take to get the P.A. fired back up?  It can take as long as six months (and sometimes even more)?  That means the departed doctor is out of network with all the plans!  This exposes her patients to higher costs and may affect referral patterns.  This alone can be crippling to a physician who has left the super group.
  1. Leaving can also mean ending access to patient scheduling and electronic medical records.  Many super groups do not ensure access to patient scheduling or billing to enable a departing physician to get back on their feet; and this can be devastating.
  1. Noncompetes can play a big role in how a departing physician gets back on her feet.  Ideally she will know that being solo is not as good as being part of a larger practice.  But what if the super group imposes a restriction on the departing physician that prevents her from being part of another group?  This is common and often very harmful, since some physicians who depart super groups have no effective options but to join other groups.

Super groups exist to benefit physicians.  It makes no sense that they would be used to harm them, which is precisely what can happen (and sometimes does happen) if physicians do not pay good attention to the “back end” as well as they do to the “front.”  That means things like—

  1. Making sure that, wherever possible, the departing physician is afforded enough time to get back on her feet professionally.  She will need time to get a new practice formed, to get a new Medicare provider number and to get back on insurance plans;
  1. Ensuring the departing physician has adequate access to medical and scheduling records;
  1. Carefully considering whether or not noncompetes make any sense.  Some may say that it is important to protect the new practice (like the old one), but these are different sorts of practices.  They are not built from the ground up.  They are built because successful competitors who have been in business for years decided essentially to “loan” their practices to the super group in order to obtain certain unique advantages.

Super group arrangements continue to grow.  Some of them even develop into fully integrated and sophisticated businesses.  Physicians who join them have to consider all “angles,” not just how good it will be or can be when they join.

read more
adminSuper Group Doctors Beware of Departure Provisions