Compliance from a health care perspective – Are you covered?

November 20, 2021

Are you aware that payer enrollment is the Gatekeeper of your revenue cycle? Enrollment, along with credentialing, prevents fraud by validating all your company information. The CMS program utilizes the IRS, the Social Security Administration, the Office of the Inspector General and the state Department of Health for state licensure to validate information. Fraud prevention occurs on many levels. The active sites of your locations are verified with surveys. The competencies of your crew-drivers and technicians are validated by their licensure, certification, training, and experience. Lastly, your vehicles by validating their location, what they are equipped with, their licensure and registration. Without an enrollment, your geographic locations of service could not be established, and your reimbursement could not be calculated effectively. Even if you have opted to be an out-of-network provider, there are some payers that you will have to enroll with. For those payers that do not require an enrollment you must establish a profile, or you will not be reimbursed.

You must have a valid and active enrollment with every government (state and federal) payer, or you will not be reimbursed.

Are you looking out for these compliance warning signs? You should be updating your locations with CMS within 30 days. Any changes to ownership, including death are reportable within 30 days. Currently the Social Security Administration plays an active role in determining validation against applicants for the first time or on renewal applications. Changes to managing control also fall within this timeline and category. Any reportable adverse events should also be reported within this time frame. Failure to do so could prevent your staff or your billing agent from sending claims and could cause you to lose your billing privileges.

Failure to stay on top of your commercial enrollments is also very important. Whether or not you contract, keeping your licensure up to date, your locations up-to-date and your contact information up to date are all important facets that allow your billing agent to facilitate the Electronic Data Interchange process and keep your claims and your reimbursement moving. Many issues are caused by old information not being updated, especially with the lack of a current contact to notify, when there are problems that occur. Also, when creating updates, it is important to update all payers, as this can cause many reimbursement problems. Without an active Provider ID, you will not be able to send claims and will receive rejections.

At Integra Connect, our Provider Enrollment and EDI team have an ongoing commitment to our providers to educate and provide the subject matter resources to help our clients stay ahead and on top of their enrollment plan.