Medicare is a very complex system consisting of a plethora of manuals,
transmittals and regulations. Weaving through the maze can be difficult.
However, this complexity also brings variety that can lend to opportunity and
business strategy when completing your Medicare provider enrollment. One of the
things to be mindful of is that healthcare practitioners have options when
wanting to enroll under Medicare to bill Medicare recipients for services.
Participating in the Medicare program as a “Provider”; allows you to bill
Medicare for services. It also means you are willing to accept “Medicare
assignment” (accepting Medicare’s designated fee schedule) for those services.
You have a few options to consider before initiating the application process.
Here’s a brief overview of options:
1. Enrollment as a Physician or Non-Physician Provider (CMS-855I
Application): this application is used by individual Physician or Non-Physician
Providers (which includes Physical therapist In Private Practice; often referred
to as PTIP). This process allows many individual practitioners to enroll as a
provider.
2. Enrollment as a Clinic/Group Practice (CMS-855B
Application): this application is used by Group Practice
Providers (GPP’s) or other organizational suppliers.
Multiple practitioners working together as a group, includes
Physical Therapists. This can be a cost effective way for
several practitioners to consolidate their resources for
group bargaining power and lower overhead.
3. Enrollment as an Institutional Provider
(CMS-855A-application): this application is used by
institutions who meet specific criteria to bill as an
institution. This includes Outpatient Physical
Therapy/Occupational Therapy/Speech Pathology Services. This
option can provide a structure for multiple disciplines or
professionals who are working together to grow across a
larger geographic radius and consolidate resources to create
a more comprehensive program.
Source: http://www.cms.gov
When considering what is the best option for your practice
there are some key factors and questions you will want to
ask. While this listing may not constitute all of your key
variables it will provide you with a good baseline to
initiate your decision making process.
• Regulatory: The regulatory considerations are
different for the various provider applications. Each type
of provider type comes with its own set of regulatory
chapters both on a federal and a state level. Even though
Medicare is writing the national regulatory guidelines, the
state (DHHS- Department of Health and Human Services) will
enforce those through their survey process as will the
Fiscal Intermediary (FI) in their Local Coverage
Determinations (LCD’s). You will need to be aware of all of
these when choosing. Here are some samples of variations in
the different enrollments.
o Rehab Agencies are considered Part A providers because they fall
under the category of institutional providers but when
therapy is involved outpatient regulations for services
apply since separate guidelines are not written.
o PTIP’s require direct line of sight supervision between a PT and
a PTA meaning the PT would need to be within sight at all
times. On the other hand, a Rehab Agency requires direct
access to supervision but not direct line of sight meaning
the PT could be off site as long as the PTA can gain
immediate access for supervision if needed. Keep in mind
this can also be influenced by the state practice act which
can change stringency accordingly.
o Geography- A PTIP will typically enroll for a particular
location/clinic where a Rehab Agency or GPP may enroll for a
series of clinics or locations. In a Rehab Agency the first
location is the primary site and other locations are often
considered extension sites. A Rehab Agency can actually
broadcast an entire state. This allows you to consolidate
operations at one location while still having the ability to
grow additional locationswithout extensive overhead.
o Credentialing- is another variation of enrollment. For PTIP and
GPP’s there are a series of steps and a wait time in the
credentialing process for each new practitioner. For a Rehab
Agency because you are enrolling as an institution this
process involves fewer steps and an expedited credentialing
since the umbrella structure is different.
• Clinical- Clinical programming is another
determining factor of choice. PTIP’s and providers within a
GPP’s often have direct oversight of one or a small number
of locations that can create an ease of oversight. GPP’s can
have many operational variations among them from clinic to
clinic. If you are considering comprehensive programming or
specialty clinical programming with multiple
disciplines/providers you may want to look at a Rehab Agency
since it requires coordination of care on behalf of the
patient regardless of locations. Processes and systems are
uniformly structured so that practitioners follow the same
clinical operations across locations.
• Quality—Quality regulations will vary as well.
Since the survey process is different for each type of
provider the requirement of quality standards vary as well.
For instance, a Rehab Agency will require an on-site survey
that is one or more days to review a number of safety and
quality standards which are more involved than an individual
clinic survey. However, Rehab Agency extension site surveys
are more abbreviated and you can often complete more than
one in a day depending on geography. Rehab Agencies also
require a Professional Advisory Committee (PAC) so if you
are looking for higher quality standards this will provide
you with organizational structure for guidance.
• Billing—Is also different depending on what type of
provider enrollment you choose. PTIP’s and GPP’s bill
differently than Rehab Agencies (Institutional Providers).
PTIP’s and GPP’s bill on 1500 outpatient claim forms while
Rehab Agencies bill under Institutional claim forms or UB’s.
You will want to ensure your billing entity is knowledgeable
for the enrollment you choose.
• Timing- Is another good variable to consider. Once
your application process is complete that is just the first
step. You also have to complete the survey process which is
executed by the state (DHHS). Since there is an increased
demand in each state and a shortage of surveyors the wait
time can vary by state from weeks, months and sometimes well
over a year. One way to overcome this especially for a Rehab
Agency is to use an Accrediting Body that can conduct and
complete your survey on behalf of the state. This will not
only expedite your process but will also provide you with a
higher level quality standard and stamp of approval. It does
however, come at an additional cost ranging from a few
thousand dollars to several thousand dollars depending on
how many staff you have.
While this is a finite number of considerations it is a good
baseline platform to help facilitate and formulate your
overall strategy. As you develop your short term and long
range goals consider the options that can assist you in
execution of your overall business plan.
Last revised: June 24, 2013
by Jodi Czernejewski MS/CCC
