In a December 23, 2011 Informational Bulletin, the Centers for Medicare and Medicaid Services (CMS) issued guidance to states on implementing the provider screening and enrollment requirements of CMS Final Rule 6028 (codified at 42 CFR 455 subpart E). The CMS rule provides that each state Medicaid agency must require all ordering or referring physicians and other professionals providing services under the State plan for Medicaid, or under a waiver of the plan, to be enrolled as participating provider. These individuals must also obtain a National Provider Identifier (NPI). School-based Medicaid billing rules in some states allow school-based speech therapists and audiologists to refer students for school-based speech therapy or audiology services. State billing rules may also allow school-based physical therapists and occupational therapists to prescribe or order school-based physical or occupational therapy services. Under CMS Rule 6028, these providers must obtain NPI numbers and enroll in Medicaid as participating providers. On page 13, the CMS Informational Bulletin states that “If the NPI is not provided on claims for payment or the ordering or referring provider is not enrolled in the Medicaid program, States must deny such claims.”
Currently, although a school district is enrolled as a Medicaid provider, its individual school-based providers are not, with few exceptions. Likewise, the school district maintains an NPI for Medicaid billing purposes, but individual school-based providers usually do not. The changes required by CMS Rule 6028 potentially pose major revenue disruptions and administrative burdens for some school districts. For instance, some school-based providers may not wish to enroll in Medicaid and the school district may not be able to enforce the requirement; this could lead to a serious reduction in Medicaid revenue. In addition, the school district’s claims will be denied for services provided based on orders or referrals by community physicians who are not enrolled in the Medicaid program.
In the Preamble to the CMS Rule 6028, CMS addressed public comments that expressed concerns about the impact of the Rule on school districts. Although CMS elected not to exempt school-based providers from the NPI and enrollment requirements, CMS stated: “However, as a way to minimize the administrative burden of enrolling additional providers, State Medicaid agencies may implement a streamlined enrollment process for those providers who only order or refer, that is, who do not bill for services, similar to the CMS-855-0 process in the Medicare program. Additionally, State Medicaid agencies may delegate to State or local governmental agencies, such as public school districts, the responsibility to screen public school-based providers and to assign unique provider identification numbers for claims identification.”
State Medicaid agencies must submit a state plan amendment (SPA) to CMS by April 1, 2012 providing assurances that they will comply with the requirements of CMS Rule 6028. Based on its statements in the Preamble to CMS Rule 6028, CMS intends that states will have flexibility with regard to the screening and enrollment of ordering and referring school-based providers. As the states develop their SPAs, it may be imperative for school districts to begin coordinating with their respective state Medicaid agencies to reduce the potential for administrative burdens and adverse financial outcomes.