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Foundations of the Billing and Collections Process

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What to do When the Unthinkable Happens

No office expects it… you go to work; you go home and get up the next day to start all over again. The phone rings and you cannot believe your ears. You have worked there for years and now everything has changed in just one phone call. No one expected it. We are not talking about an unfavorable audit…it is the call you never want to receive. We expect the doctor to be invincible…doctors are healers…doctors don’t get sick…they don’t die… but that is exactly what just happened. And in the past two years, several of our members have found themselves in this terrible situation.

Most offices are not prepared for this challenge and they understandably struggle with what to do next. Not only do staff members have to deal with their own feelings, but also how they will tell the patients and how those patients will continue to get the care they have been receiving. In a solo practice, this can be a very big challenge.

An office might initially think of bringing on a Locum Tenens doctor, but this is not allowed in this situation. When utilizing a Locum Tenens provider in the office, Box 24J of the 1500 billing form contains the NPI of the doctor not available. However, in this instance, the NPI of the deceased doctor is no longer valid and will be terminated.

One Medicare Administrative Contractor goes on to say, “Since contractors are required to terminate a deceased provider’s enrollment, you cannot submit a locum tenens service under the deceased provider’s National Provider Identifier (NPI). The performing physician must submit the services under their own NPI.” Palmetto cites the Program Integrity Manual – CMS 100-08, chapter 15, §15.28 – as the source for its answer.

How will Medicare and other entities such as NPPES know that the provider has died?

We look to Medicare’s Regulations and Guidance:

15.28 – Deceased Practitioners (Rev. 898, Issued: 09-06-19; Effective: 10-07-19; Implementation: 10-07-19)

A. Reports of Death from the Social Security Administration (SSA)

Contractors, including the NSC MAC, will receive from CMS a monthly file that lists individuals who have been reported as deceased to the SSA. To help ensure that Medicare maintains current enrollment and payment information and to prevent others from utilizing the enrollment data of deceased individuals, the contractor shall undertake the activities described below. 

Once the contractor verifies the report of death, it shall notify the provider or supplier organization with which the individual is associated that it needs to submit a Form CMS-855 change request that deletes the individual from the provider or supplier’s enrollment record. If the provider fails to submit this information within 90 calendar days of the contractor’s request, the contractor shall deactivate the provider’s Medicare billing privileges in accordance with 42 CFR §424.540(a)(2).  (DMEPOS Suppliers Only – If a DMEPOS supplier fails to submit this information within 30 calendar days of the contractor’s request, the contractor shall deactivate the supplier’s billing privileges in accordance with 42 CFR §424.57(c)(2).)  

The office may decide to hire a physician to permanently replace the deceased provider, but this will take time. If you do hire a physician to take over, it is important to be aware of Medicare’s credentialing requirements. A chiropractor must be enrolled with Medicare to provide services to a beneficiary. There is no workaround for this requirement. In addition to Medicare, enrollment requirements with other payers must be verified.

So how do you handle the current patient load outside of cash patients in a solo practice? Medicare patients need to be referred to other Medicare providers in the area. We would encourage you to reach out to your malpractice carrier for guidance on how to go about this appropriately. As far as other patients, the new physician could see them on a cash basis if he/she is not enrolled with the payers at this time. You could bill the payer, but the services will go to an out of network benefit.  We recommend that you seek individual payer requirements and advice.

In the midst of all this chaos, there are the expectations of the Office of Civil Rights relative to HIPPA regulations that must be considered. HIPPA compliance requires that proper notification be provided to patients regarding the location of stored records and the final custodian of records.

There is a lot to consider during such a difficult time. Don’t accidentally do the wrong thing with the right intention, by adding a provider who isn’t authorized to see the patient. The continuing success of the practice depends on properly handling the many aspects of such a tough situation. Never hesitate to call your team here at KMC University when these difficult and unusual situations come up.

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By Yvette Noel

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