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ASK BEN: Medicare Q & A December 2011 Update Print E-mail
Written by Benjamin L. Frosch   
Monday, 02 January 2012 00:00

Q:  I recently completed my fellowship and will be setting up my own solo practice next month.  I wish to set up a P.A. (Professional Association) and am confused about which documents to submit.  Do I need to submit a separate CMS 855B to get a provider number for my P.A. and then obtain a personal number by completing a CMS 855I and CMS 855R reassigning my personal benefits to my P.A.  Are all of these documents necessary? 

New Physician
Orlando, FL  

A:  Since you are the sole owner and only member of your Professional Association (P.A.), you only need to complete the CMS 855I.  Pay particular attention to section 4 (A) which you would need to complete since you are the sole owner of a Professional Association and will bill Medicare through this business entity.   However, when you apply for your personal NPI, you should also apply for a NPI number pertaining to your Professional Association utilizing its tax ID number.  You will also have to submit a Medicare Participation Agreement and EFT 558 form for electronic funds transfer.  Please refer to Medicare Registration at for specific guidance.

    Our group practice received our Medicare number last year and was entered into the PECOS system. During that process, my partners and I also revalidated with Medicare Provider Enrollment. Is it true that we will have to revalidate again by 2013 and go through this entire painful process once more? Can we start the revalidation process now in order to get it over with?

Internal Medicine
Hollywood Florida

  Its official, you must revalidate by 2013. Every provider who was enrolled in Medicare before March 25, 2011 must revalidate with Medicare in order to keep their billing privileges. However, you must wait for a letter from Medicare Provider Enrollment asking you to start your revalidation process. Your deadline for this is March 23 2013. If you do not make the deadline, your Medicare payments will be frozen until you are revalidated and updated in the Provider Enrollment Chain Ownership System (PECOS). You can revalidate utilizing the appropriate CMS855 forms or online through the PECOS website. It’s important to remember that revalidation means resubmitting your entire enrollment data and information including various supporting documents.

 I have a large geriatric practice and have started to perform more and more debridements. One of the reasons for this increase is that my nursing home patients have increased.   I am confused as to when I can and cannot bill a visit with these debridement codes. Any direction?

Geriatric Physician
Fort Lauderdale, FL

A:  Visits by the same physician on the same day as a minor surgery are included in the payment for the procedure unless a significant, separately identifiable service is also performed. As an example, a visit on the same day could be probably billed in addition to suturing a scalp wound if a full neurological examination is made for a patient with head trauma. You would attach a "25"modifer to your visit code which means it is a separately identified service.   Billing for a visit would not be appropriate if the physician only identified the need for the procedure and confirmed allergy and immunization status.

The initial consultation for evaluation of the problem by the physician to determine the need for surgery may be covered, but this policy only applies to major surgical procedures. The initial evaluation is always included in the allowance for a minor surgical procedure. Please refer to the CMS (Centers for Medicare and Medicaid) website for further instructions and a complete list of minor and major surgical procedures.

Mr. Frosch is the President of Frosch Medical Consultants, Inc. in Plantation, FL.                  

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Last Updated on Monday, 16 January 2012 13:09
ASK BEN: Medicare Q & A Fall 2011 Update (cont.) Print E-mail
Written by Benjamin L. Frosch   
Sunday, 13 November 2011 10:47

   Our practice does accept Medicare patients but we are not happy with Medicare's policies and payments in addition to all the trouble with denials, resubmission, etc. I would like to become a private practice that accepts no insurance whatsoever. I have heard that I cannot stop being a Medicare provider even if I opt out of Medicare. I could not have patients that hold a Medicare card as a private patient and charge my regular rate. Is it true?  

How can I have a practice that does not have to deal with health insurance companies or Medicare and where all patients would be self pay regardless of what insurance they may have? If the patients want to submit a claim to their insurance, that would be between them and their insurance company. In my view, we should be able to just hang a sign saying "We accept no insurance. Every patient is personally responsible for the payment of all charges which are due at the time of service". However, it seems impossible.

General Practice Medicine
Miami, FL

A: It is not impossible; however it may be difficult to find patients that agree to that financial arrangement. With respect to Medicare beneficiaries, if you decide to opt out of the Medicare program, you can charge Medicare patients whatever you wish. However, there are a variety of steps that must be taken to "opt out" and comply with Medicare regulations. For starters, in order for you to "opt out" you would need to complete and sign an "opt out affidavit" and submit it to Medicare Registration at First Coast Service Options, Inc. (FCSO). Thereafter, you would need to provide each of your Medicare patients with an "opt out contract" that specifies the conditions such as the fact that they are totally responsible for your fees and cannot even submit a claim to Medicare unassigned. There is a lot of detail to "opting out" of the Medicare program, please refer to for further information.

As far as private insured patients, you are not obligated to accept their insurance and you can charge them your regular rate at the time of service assuming you have no contractual obligations with any insurance company.

Mr. Frosch is the President of Frosch Medical Consultants, Inc. in Plantation, FL.

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Last Updated on Wednesday, 23 November 2011 13:03
Medicare Q & A: Summer 2011 Print E-mail
Written by Benjamin L. Frosch   
Wednesday, 03 August 2011 12:59


Q.   We are a diagnostic center (Independent diagnostic testing facility) that has been in business for almost 5 years and will need to revalidate with Medicare provider enrollment in the near future. I heard that Medicare is now charging for revalidation. If this is true, what is the process for submitting payment and what is the cost?

Administrator, IDTF
Miami, FL

A. Effective Friday March 25, 2011, Medicare contractors will begin collecting application fees with certain providers/supplier enrollment applications (both paper and online applications). The application fee is currently $505 for calendar year 2011; however, this fee will vary from year-to-year based on adjustments made pursuant to the Consumer Price index for Urban Areas.

These application fees do not apply to physicians, non-physician practitioners, physician organizations, and non physician organizations. All institutional providers of medical or other items or services or suppliers must pay the application fee. All application fees must be submitted via paper check, until the Centers for Medicare & Medicaid Services (CMS) specifies a mechanism for submitting electronic funds at a future date.

Medicare provider enrollment will not be able to process any CMS applications without the proper application fee having been paid and credited to the United States treasury or an approved hardship exception. If the fee is not submitted, the application will be rejected or billing privileges revoked unless a hardship exception request is subsequently granted. Please refer to for further information. 

Q:  I am a cardiologist that provides interpretation services to an Independent Diagnostic Testing Facility (IDTF).  Specifically, I provide the supervision and interpretation services on the diagnostic center's patients in addition to patients that I refer to the center.  They informed me that because I am their interpreting physician, the IDTF couldn't bill for the interpretation on my own patients.  I was advised that I must bill Medicare Part B directly for the interpretation provided at the diagnostic center on my own patients.  Are they accurate with this information?

Palm Beach County, FL 

A:  According to the Florida Medicare Local Coverage Determination (LCD) policy on IDTF's, when the technical component of a test is performed by the IDTF and the interpreting practitioner is the practitioner who ordered the test, the IDTF cannot bill for the interpretation.   The interpreting practitioner must bill the interpretation since the IDTF cannot bill for the interpretation when the interpreting physician is the referring physician.    You can go to  and refer to the LCD addressing IDTF's for further information.  

Q:  We are an Internal Medicine Practice that moved to a new office about two months ago.   We did the typical things that any business does when they move which includes completing and submitting forwarding address card to the postal service.  Since we moved to our new office, Medicare stopped submitting checks to us.  We called Medicare Customer Service and they advised us that since they were not notified of our new office, they would have to hold our checks until we complete and submit a variety of Medicare documents.  We called Customer Service numerous times and were given different instructions. Can you provide us with advice on how to receive our Medicare checks?  This is hurting our cash flow!

Internal Medicine
Gold Coast, FL

A:  When you relocate to a new office or add an additional location, you are obligated to notify Medicare Provider Enrollment within thirty days.  The US Postal Service will not forward Medicare checks even though you completed the forwarding address card.  The post office returns these checks to Medicare.  

What you need to do is complete a CMS 855B pertaining to this change of information and your new practice location and pay to address.  You also need to complete a CMS 588 EFT (Electronic Funds Transfer) form because Medicare will not mail you any more check after you are caught up.  Medicare now requires that payments be directly deposited into your group's bank account. 

Additionally, you may want to contact Customer Service to find out if you and/or any members of your group need to "revalidate" your PTAN numbers.  Once Medicare Provider Enrollment has processed all of the documents, you will receive all of your back payments in addition to receiving future payments, which will be directly deposited into the group's bank account.           
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 Mr. Frosch is the President of Frosch Medical Consultants, Inc. in Plantation, FL.

Last Updated on Sunday, 14 August 2011 16:57
Medicare Q & A: Spring 2011 Update Print E-mail
Written by Benjamin L. Frosch   
Saturday, 05 March 2011 16:00

Q:   We are a ten person group practice with four partners.  We are in the midst of moving and understand that we must submit a CMS 855B advising Florida Provider Enrollment of our new location.   Our question addresses the signature requirements in section 15.  It states that it needs to be signed by an authorized official, since there are four partners, can any us sign section 15 of the CMS 855B?

Administrator, Orlando

A:    For initial enrollment and revalidation, the certification statement (section 15) must be signed and dated (preferably in blue ink) by an authorized official.  An authorized official is an appointed official to whom the organization has granted legal authority to enroll it in the Medicare program, make changes or updates to the organization's status, and commit the organization to fully abide by the statues, regulations, and the program instructions of the Medicare program. 

            Assuming that all four of the partners are established authorized officials, any of the four can sign.  However, if you are not sure, you may want to check with Florida Medicare Provider Enrollment.  Although there are four partners in your entity, are all four partners enrolled and approved by Medicare as authorized officials? If you find out that there is only one individual partner recognized by Medicare as an authorized official, you may want to consider adding all the partners of the group as authorized officials.


Q: Up until a few weeks ago, I was an employee of a group.  I have decided to leave the group and start my own practice.  My problem is that I do not know my Medicare PTAN, and because of my adversarial departure from the group, they are taking the position that they do not have to give me my Medicare PTAN.  What would be the quickest way for me to obtain my Medicare provider number from Florida Medicare?

Cardiologist, Miami

 A:   The easiest way to obtain your Medicare provider number is if your former employer provides you with the Medicare approval letter which was issued when you joined their group.  That letter would have your Florida PTAN (provider number) and NPI.   Since it sounds like that is not going to happen, you need to send a written request to Medicare Provider Enrollment, PO Box 44021 Jacksonville, FL 32231-4021.  Put in the correspondence your request for the provider number, your legal business name, NPI number, telephone and fax number.  Additionally, since you have left the group it would behoove you to submit a CMS 855R (Reassignment of Benefits) deactivating your relationship with your former employer. 


Q:   The overwhelming majority of our patients are Medicare beneficiaries.  From time-to-time, we have Medicare patients that have other third party insurance and Medicare is their secondary.  My question is how is a Medicare payment determined?

Billing Manager

Gastroenterology Practice, Palm Beach

A:  The Medicare Secondary Payment (MSP) is determined by a series of calculations and comparisons. The primary insurer's claim processing details on their explanation of benefits (EOB) is needed to determine the secondary payment amount.   Three calculations are made per procedure; the lowest of the three is the secondary payment. 

1.) Determine what the Medicare primary payment would be.

  • Note the Medicare allowed amount for the procedure
  • If applicable subtract the Medicare deductible amount applied towards the procedure
  • Multiply the difference by the appropriate percentage:  62.5%, 80%, 85%, or 100% depending on the procedure code and/or provider

2.) Compare the Medicare allowed amount to the primary insurer's allowed amount, select the higher of the two

3.) Subtract the primary insurer's paid amount from the billed amount


Q:  I just opened up my own surgical practice and need some information from Medicare pertaining to global surgery days and the relative units (RVU) for a particular code. Can you direct me to that information?

Surgeon, Broward County           

A: The Centers for Medicare and Medicaid Services (CMS) make that information available on their website.  After you access their website, you need to find the "National Physician Fee Schedule Database Tool".  Click on that icon and you will find all the indicators which will have global surgery days including: pre-op, intra-operative, and post-op days.   You may also access that website by going to, which will direct you to that National Physician Fee Schedule database.

ABOUT THE AUTHOR:  Benjamin L. Frosch is the President of Frosch Medical Consultants, Inc. in Plantation, FL. 
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Last Updated on Sunday, 14 August 2011 16:58
Breaking it down: Analysis of 2011 OIG Work Plan (Medicare Part B) Print E-mail
Written by Benjamin L. Frosch   
Friday, 03 December 2010 11:04


With a few thousand staff members throughout the United States, the Office of Inspector General (OIG) plans and performs audits, investigations, evaluations, and legal activities pertaining to the Department of Health and Human Services (HHS).   With the Issuance of the 2011 OIG Work Plan there are a variety of important Medicare issues that they will evaluate pertaining to Medicare physicians and other health care providers.  This may be a good opportunity to evaluate compliance in your practice with respect to the following Part B subjects that are in the work plan. With a variety of federal agencies looking closer at Medicare fraud and abuse than ever before, it is very clear that there is a zero tolerance for Medicare fraud and abuse. The following is a list of what I think are some of the hottest "subjects" targeted in the 2011 OIG Work Plan:


This is definitely going to be a subject under the microscope in 2011 and beyond.  The OIG is going to review Evaluation and Management (E&M) claims to identify issues in the coding of E&M services. Medicare paid $25 Billion dollars for E&M services in 2009 which represents 19% of all Medicare Part B payments. They will also be reviewing the extent of potentially inappropriate payments for E&M services and the consistency of E&M medical review determinations by Medicare contractors.

Also Medicare contractors throughout the United States have noted an increase in the frequency of medical records with identical documentation across services. The OIG plans to review multiple E&M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments.


The OIG has decided to continue reviewing physician coding of place of service on Medicare Part B claims for services performed in Ambulatory Surgical Centers (ASC) and hospital out-patient departments. Federal regulations provide for different levels of payment to physicians depending on where the services are performed.  Medicare pays a physician a higher amount when a service is performed in a non-facility setting such as a physician office than it does when a service is performed in a hospital outpatient department or, with certain exceptions, in an ASC.  The OIG will continue to evaluate whether physicians properly coded the place of service on claims provided in ASC's and hospital outpatient departments.


As we can all see E&M services are absolutely under the microscope. Under the global surgery fee concept, physicians bill a single fee for all of their services that are usually associated with a surgical procedure and related E&M services provided during the global surgery period. The OIG will evaluate whether medical practices related to the number of E&M services provided during the global surgery period have changed since the global surgery fee concept was developed in 1992.


Diagnostic tests will be under scrutiny in 2011 and beyond.  The OIG will review Medicare payments for high cost diagnostic tests to determine whether they were medically necessary. The Social Security Act provides that Medicare will not pay for items or services that are "not reasonable and necessary". The OIG will address the extent in which the same diagnostic tests are ordered for a beneficiary by primary care physicians and physician specialists for the same treatment.   However, there will be other OIG issues for diagnostic tests. Physicians  are  paid  for services  pursuant  to  the  Medicare  physician  fee  schedule,  which  covers  the major  categories  of  costs,  including  the  physician  professional  cost component,  malpractice  costs,  and  practice  expense.  The  Social  Security Act, §  1848(c)(1)(B),  defines  "practice  expense"  as  the  portion  of  the resources used  in  furnishing  the  service  that  reflects  the general  categories of expenses,  such  as  office  rent, wages  of  personnel,  and  equipment.  Certain imaging services will be under focus with respect to the practice expense components. The OIG will determine whether Medicare  payments  for  Part B Imaging reflect the expenses incurred  and  utilization  rates.   


While there is no doubt that the Florida is a geographic area with a high density of IDTF's, the OIG will be reviewing services and billing patterns in areas such as Florida due to high concentrations of IDTF's.   IDTFs must meet regulatory performance requirements in accordance with 42 CFR to obtain and maintain Medicare billing privileges. In 2006, the OIG concluded that there were numerous problems with IDTF's including non-compliance with Medicare standards and potential improper payments of over $70 million dollars. This issue leads into;


The OIG is going to select certain IDTF'S that are enrolled in Medicare to determine the extent in which they comply with the ITDF Medicare standards. IDTF's received payments of almost $900 million dollars in 2009. Federal regulations require IDTF's to certify on their enrollment application that they comply with the seventeen CMS standards.  Such standards include requirements that IDTF's comply with all federal and state licensure and regulatory requirements that are applicable to the health and safety of patients, provide complete and accurate information on their Medicare enrollment application, and have the appropriate technical staff and physicians who are proficient with respect to the tests they perform.


The OIG will evaluate if outpatient physical therapy services provided by independent therapists are in compliance with Medicare reimbursement regulations and guidelines. Previous OIG work plans have identified claims for therapy services provided by independent physical therapists that were not reasonable, medically necessary, or properly documented.  They will focus on independent therapists who have a high utilization rate for outpatient physical therapy services and will determine whether the services that were billed to Medicare were in accordance with federal requirements.   Florida once again is one of the highest areas in the United States when it comes to providing physical therapy to Medicare beneficiaries compared to the other regions of the country.


There is a concern pertaining to the extent to which clinical laboratories have inappropriately unbundled laboratory profile or panel test to maximize Medicare payments. The OIG will look into whether clinical laboratories have unbundled profile or panel tests by submitting claims for multiple dates of service or by drawing specimens on sequential days.  The OIG will also be looking at trends in laboratory utilization. In 2008, Medicare paid about $7 Billion dollars for clinical laboratory services which represent a 92% increase from 1998.


The OIG is going to take a look at the appropriateness of Medicare payments for sleep test procedures that are provided at sleep disorder clinics. A preliminary OIG review identified improper payments when modifiers are not reported for sleep test procedures. The OIG will examine Medicare payments to physicians and Independent Diagnostic Testing Facilities for sleep test procedures to determine whether they were in accordance with Medicare requirements. 


I think we can all understand why the OIG will take a look at this issue. They plan on reviewing Medicare claims with dates of service after a beneficiary's date of death to assess CMS controls to preclude or identify and recover improper payments. CMS uses several computer database systems that interface with  death  information  on  the  Social  Security  Administration's  and  the  Railroad  Retirement  Board's  systems.  

About the author:  Mr. Frosch is President of FROSCH MEDICAL CONSULTANTS, INC. in Plantation, FL.


Last Updated on Sunday, 14 August 2011 16:58
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