HHA and DME Providers Must Verify Medicare Enrollment for Referring Physicians

By Michael L. Smith, J.D., R.R.T.

(April 2, 2013) – Home health and durable medical equipment providers need to start verifying the enrollment status of their ordering/referring practitioners. The Affordable Care Act (ACA) included a provision that requires physicians and other practitioners that order home health services and durable medical equipment to be enrolled in the Medicare program even if those practitioners do not submit claims to Medicare. Currently, Medicare is providing “informational messages” to home health and durable medical equipment providers and suppliers concerning the enrollment status and specialty status of the ordering/referring practitioner. Effective May 1, 2013, Medicare will start denying claims submitted by home health and durable medical equipment providers when the ordering/referring practitioner is not enrolled in Medicare and not of the correct type/specialty to order those services. In order to avoid denied claims, home health and durable medical equipment providers need to verify the enrollment status of their ordering/referring practitioners.

Home health agencies and durable medical equipment providers may verify that their ordering/referring practitioners are enrolled in Medicare and that those providers are the correct type/specialty to order the services through Medicare. Medicare has compiled a list of all the currently enrolled practitioners that are of the correct type/specialty to order home health and durable medical equipment services, which is available on the Medicare website. Unfortunately, the list is 17,566 pages long and it is uncertain how often Medicare will update the information.

The list compiled by Medicare only includes individual practitioners and not the groups where those practitioners practice. Medicare requires that the individual practitioner that ordered/referred the home health or durable medical equipment service be identified on the claim submitted to Medicare and not the practitioner’s group. Medicare will deny a claim submitted with an organizational provider number as the ordering/referring practitioner.

Physicians and other ordering/referring practitioners that have opted out of Medicare may still enroll in Medicare for the sole purpose of ordering/referring for home health and durable medical equipment services. Practitioners may enroll in Medicare through the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) or by submitting paper enrollment forms to the Medicare Administrative Contractor.

Medicare has also published a list of the type/specialties of practitioners that may order home health and durable medical equipment services on its website. The following practitioner types may order/refer home health and durable medical services under the ACA if they are enrolled in Medicare.

• Certified Nurse Midwives
• Clinical Nurse Specialists
• Clinical Psychologists
• Clinical Social Workers
• Interns, Residents, and Fellows
• Nurse Practitioners
• Physician Assistants, and
• Physicians (Doctors of Medicine or Osteopathy, Doctors of Dental Medicine, Doctors of Dental Surgery, Doctors of Podiatric Medicine, or Doctors of Optometry)

An optometrist is only permitted to order/refer laboratory and x-ray services payable under Medicare Part B and DMEPOS products/services.

Home health agencies and durable medical equipment providers need to begin verifying the enrollment status of their ordering/referring practitioners in order to avoid having those claims denied. The individual ordering/referring practitioner’s information should be included on the claim instead of the number for the practitioner’s practice organization.

Michael L. Smith, JD, RRT is board certified in health law by The Florida Bar and practices at The Health Law Firm in Altamonte Springs, Fla. This article is for general information only and is not a substitute for formal legal advice.

This article was originally published in Advance for Respiratory Care and Sleep Medicine.