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Nursing Home Medical Assistance Per Diem Payments To Be Denied If Resident's Attending Physician Not An MA Certified Provider

In a Medical Assistance (MA) Bulletin issued April 1, 2016, the Department of Human Services (DHS) stated that effective September 25, 2016, physicians and practitioners who order, refer or prescribe items or services for MA beneficiaries must themselves be enrolled in the MA Program. The Bulletin states that to "track" this requirement, DHS will look to the claim field for the "ordering or referring physician" and the NPI number associated with that physician. If that physician is not on file as an MA provider, then the claim will be denied.

MA-participating nursing homes are required to report the resident's attending physician and his/her NPI as part of the UB-04 claim submission to DHS. Based on the provisions of the MA Bulletin, and subsequent guidance we have received from DHS, if the attending physician for an MA resident is not an MA enrolled practitioner, then the nursing home's MA per diem claim submission for that resident will be denied, and the facility will be unable to collect payment from the MA program for services rendered to the MA beneficiary.

Given these significant financial consequences, it is imperative for nursing facilities to ensure that the attending physicians who provide care and services to their MA residents are enrolled and certified for participation in the MA Program. There are several ways to address this issue, including, through contract (in the context of facility Medical Directors) or through a credentialing process with respect to independent attending physicians.

If you would like to discuss this issue and the impact on your facility, please do not hesitate to contact David Marshall at (717) 620-2424.

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