Medical Economics Feature - May 2008
By Ken Ortolon
When Amarillo obstetrician-gynecologist Michael Williams, MD, moved from a group to a solo practice and applied for a new Medicare provider number in December 2006, his practice manager didn't think it would take nearly 11 months to get it.
Elaine Wells, of Professional Health Care Management, says she never received a letter from TrailBlazer Health Enterprises, the Texas Medicare carrier, requesting more information needed to process Dr. Williams' application. She submitted an electronic funds transfer application five separate times. Then, when the TrailBlazer analyst processing the application quit, TrailBlazer informed her the application had been lost and had to be resubmitted. Finally, TrailBlazer apparently confused Dr. Williams with another physician of the same name who also was applying for a Medicare provider number, slowing the approval process even further.
Ms. Wells said the delay had an "absolutely huge" negative impact on Dr. Williams' practice because he couldn't bill either Medicare or Medicaid while TrailBlazer processed his application.
"This also delayed his Medicaid number because you can't get a new Medicaid number until you get a Medicare number," Ms. Wells said.
Dr. Williams' case might be a worst-case scenario, but other Texas physicians also have experienced lengthy delays in getting their Medicare enrollment applications processed by TrailBlazer, which currently has a backlog of about 10,000 pending applications. TrailBlazer and Texas Medical Association officials, however, are trying to resolve some of the issues creating the backlog, and processing times have become shorter.
Still, officials warn that the backlog may not go away any time soon because of the huge volume of applications still coming in.
Barbara Harvey, TrailBlazer vice president for program integrity, says there are several reasons for the backlog and delays in application processing. First, TrailBlazer has seen a significant increase in the number of provider applications it receives. And that increase does not appear to be letting up.
"For the first quarter of 2008, we received about 22 percent more applications than we did for the first quarter of fiscal year 2007," Ms. Harvey said.
Part of that increase likely is the result of more out-of-state physicians moving to Texas since passage of medical liability reforms in 2003. The Texas Medical Board (TMB) had a backlog of about 2,500 licensure applications as of mid-March. In 2007, TMB received additional funding to speed its licensure processing, and that is impacting Medicare enrollment applications.
"And, of course, when they [TMB] get their backlog out, it becomes part of my backlog," Ms. Harvey said.
The second reason for the backlog is the large percentage of incomplete applications that TrailBlazer receives. Ms. Harvey says some 60 percent of applications submitted a year ago required additional information to process.
Finally, she says, reviewing the applications is a "very manual" process that simply takes a lot of time.
While 10,000 applications are still pending, that does not mean 10,000 Texas physicians are waiting for Medicare numbers, Ms. Harvey says. For example, when a new group practice is set up, it must apply for a provider number for the practice as well as for each physician who will be part of that group. Also, each physician also must apply to reassign his or her benefits to the group. Thus, there could be hundreds of applications pending for a large group.
At the height of the backlog, TrailBlazer took 75 to 80 days on average to process a clean application. Applications needing additional information took even longer. TrailBlazer's contract with the U.S. Centers for Medicare & Medicaid Services (CMS) requires it to process at least 80 percent of initial provider enrollment applications within 60 days, and to process applications involving change of address, change of practice, or other situations that require a physician to apply for a new provider number within 45 days.
Houston ophthalmologist Keith Bourgeois, MD, chair of TMA's Council on Socioeconomics, says the problems became worse when CMS issued a new enrollment form and new regulations in May 2006. The new rules require physicians to submit their national provider identifier (NPI) and a copy of the NPI notification furnished by the National Plan and Provider Enumeration System. In addition, they also require physicians to complete an authorization agreement for electronic funds transfer.
Those changes increased the number of applications completed incorrectly, Dr. Bourgeois says.
He says another problem has been CMS's reluctance to give TrailBlazer funding for customer support staff, making it hard for physicians or their staff to get information about their pending applications.
"There's this huge frustration because they [TrailBlazer] aren't returning e-mails, and it's pretty hard to get them on the phone," he said.
At one point, TrailBlazer's customer support lines received some 32,000 calls a week from physician offices wondering about the status of their enrollment applications.
Now, things appear to be getting better. Ms. Harvey says TrailBlazer has added 24 new staff members to speed application processing. That has reduced processing times substantially, she says. TrailBlazer now meets the requirement that it process at least 80 percent of applications within 45 or 60 days, at least for clean applications, she added. Applications requiring additional information are averaging about 90 days to complete.
Ms. Harvey says Web-based training tools, available since August, seem to have helped. (See " A Joint Effort .") The percentage of incomplete applications received has dropped from 60 percent to about 40 percent, she says. "But 40 percent is still awfully high," she added.
Even though there has been progress, TrailBlazer may not clear the backlog any time soon.
"Because of our 20 or so percent increase in receipts, it's hard to actually reduce the backlog, but what we are doing is processing them more timely," Ms. Harvey said.
Also, TrailBlazer recently won the contract to be the Medicare provider for Oklahoma, Colorado, and New Mexico, which will increase its Medicare enrollment caseload. Ms. Harvey, however, says staff members were added to handle the new contract, which became effective March 1.
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by e-mail at Ken Ortolon .
A Joint Effort
The Texas Medical Association and TrailBlazer Health Enterprises collaborated on Web-based tools to help physicians deal with problems in enrolling in Medicare or applying for new Medicare provider numbers.
Physicians can check the status of their enrollment applications on the TrailBlazer Web site .
TMA and TrailBlazer also jointly posted aids to educate physicians and their office staff on when they need to apply for a new provider number and how to complete the applications.
They are on the TMA Web site , or you can log on to the TrailBlazer site .
There are three separate presentations, one for each of the three types of enrollment forms. Those forms include CMS-855I, used by individuals enrolling or making changes; CMS-855B, used by groups enrolling or making changes; and CMS-855R, used when physicians reassign their benefits to a new group practice.
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