Frequently Asked Questions
1. Who at WPS do I contact for questions on the Provider-Based attestation and who do I submit such documentation to?
At WPS, our Audit Advisement team is responsible for reviewing and fielding questions on the provider-based attestation process. Below are the contact names and email addresses for the two main provider-based contacts at WPS.
Name: Darlis Lupton
Title: Provider Based Attestation Coordinator in the Audit Advisement Area
Email: Darlis.Lupton@wpsic.com
Name: Chris Severson
Title: Audit Advisement Supervisor
Email: Chris.Severson@wpsic.com
Provider-Based Attestation Submission Address:
Delivery/Overnight Service:
WPS Medicare
Attn: Chris Severson
Medicare Audit Advisement
3333 Farnam Street, Suite 700
Omaha, NE 68131
Regular Mail Service:
WPS Medicare
Attn: Chris Severson
Medicare Audit Advisement
P.O. Box 1604
Omaha, NE 68101
2. Who at WPS do I contact for questions on the CMS Form 855 (Enrollment Application Form) and who do I submit related documentation to?
At WPS, our Provider Enrollment team is responsible for reviewing and fielding questions on the CMS Form 855 Enrollment process. Below are the contact names and email addresses for the two main Provider Enrollment/855 contacts at WPS.
Name: Andrew Drinnin
Title: Provider Enrollment Program Analyst
Email: Andrew.Drinnin@wpsic.com
Name: Nic Chesnut
Title: Provider Enrollment Supervisor:
Email: Nic.Chesnut@wpsic.com
CMS Form 855 Enrollment Submission Address:
Delivery/Overnight Service:
WPS Medicare
Attn: Nic Chesnut
Medicare Provider Enrollment
3333 Farnam Street, Suite 700
Omaha, NE 68131
Regular Mail Service:
WPS Medicare
Attn: Nic Chesnut
Medicare Provider Enrollment
P.O. Box 1604
Omaha, NE 68101
Although separate areas handle each of the processes (i.e. 855 and Provider-Based Attestation) if it is all submitted to one address, we will ensure that each piece gets to the appropriate team for completion.
3. Since Provider-Based Attestations are no longer required to bill services for my facility as provider-based, rather than free-standing, what is required?
Although there is no required certification or review, providers must still comply with the requirements of 42 CFR 413.65 and all other applicable regulations. A facility is only allowed to bill as provider-based if they meet the various financial and clinical integration and other criteria as stated in the regulations. Although the attestation and review process to document that you have met those criteria is voluntary, the requirement that you meet the criteria themselves is still effective. If later review determines that the criteria were not met, there is the possibility that additional money reimbursed due to billing as provider-based, rather than freestanding, will be recouped.
Any time you add a new service location you are required to report it to WPS within 90 days of the effective date of change, regardless of whether you are filing a provider-based attestation or not. Per 42 CFR 424.520(b), failure to report such changes within 90 days may result in the deactivation or revocation of the provider's Medicare billing privileges. These changes must be reported by submitting a CMS form 855. See later section regarding the CMS form 855 and the proper contacts for questions or submissions.
4. Since it is not required, what is the benefit of submitting a Provider-Based attestation in those situations where one is allowed?
As mentioned above, although meeting the criteria in 42 CFR 413.65 is required, the self-attestation and review process is voluntary. If you elect to bill as provider-based, yet forgo the self-attestation and review process and are later found to not be in compliance with the regulatory requirements, CMS may recover the difference between the amounts reimbursed as provider-based and that amount that would have been reimbursed for freestanding facilities. This recovery may be made for all periods subject to reopening.
If you decide to submit a self-attestation for formal review, this increases your assurance that you are properly adhering to the provider-based criteria of 42 CFR 413.65. In addition, if CMS subsequently discovers that the facility has been billing as provider-based and an attestation has been made and approved in fact does not meet the provider-based rules, then CMS would not recover all past payments for periods subject to reopening, but instead would limit such recoupment back to the date the complete request for a provider-based determination was submitted. At the time that CMS determines that a facility that submitted a complete attestation is actually not provider-based, payment would continue for up to 6 months but only at a reduced rate as described at §413.65(j)(5).
It could benefit the provider to self-attest and obtain a determination because, under §413.65(l)(1), treatment of a facility as provider-based would cease only with the date that CMS determines that the facility no longer qualifies for provider-based status, if the reason the provider-based criteria are not met is a material change in the provider-facility relationship that was properly reported to CMS. By contrast, a provider that did not seek such a determination or obtained a determination but failed to report a material change in its relationship with the facility, could face a partial recovery of past payments. Also, a provider that does not seek a provider-based determination and incorrectly bill as such could be subject to the partial recovery of payments for all cost reporting periods subject to reopening in accordance with 42 CFR §405.1885 and §405.1889.
5. When are provider-based attestations allowed and when are they not allowed?
Provider-based determinations only serve a purpose if there is a reimbursement (payment) impact or a difference in coinsurance liability between billing as provider-based or freestanding. Neither the FI/MAC, or CMS will make determinations of provider-based status (and provider-based attestations should not be submitted) for facilities or organizations if by law their status (freestanding or provider-based) would not affect either Medicare payment levels or beneficiary liability.
Provider-based determinations will not be made with respect to Ambulatory Surgical Centers (ASCs), Comprehensive Outpatient Rehabilitation Facilities (CORFs), Home Health Agencies (HHAs), Skilled Nursing Facilities (SNFs), hospices, inpatient rehab units, facilities that furnish only clinical diagnostic laboratory tests, or facilities that furnish only physical, occupational, or speech therapy (as long as the $1500 annual cap on coverage remains suspended).
In essence, submissions and reviews will only be allowed when there is a difference in payment or beneficiary liability. When submitting an attestation, one of the questions that will be asked is, "what is the difference in payment between freestanding and provider-based status for this service?" If there is no difference, the attestation will immediately be closed with no recommendation made.
In addition, regardless of payment differences between freestanding and provider-based. Provider-based attestations will not be accepted or reviewed for the following two situations:
- When the entity is located on the floor of the main building/department of the hospital, or within the four walls of the provider's main building, or
- When the provider plans to bill the Part B (Carrier) - because provider-based attestation only impacts Part A services
Note that these exemptions listed above do not mean such entities cannot bill as a provider-based, it simply means that no self-review or attestation will be required or allowed.
6. Can I submit my attestation even though I am waiting on some of the documentation (e.g. licenses from the state)?
No. Do not submit your provider-based attestation unless all of the necessary information is included and/or available. For example, if you have not included a copy of the license showing that the main and provider-based facility are operated under the same license, or support showing that your state does not allow this, a missing information letter will be issued requesting such information. If the request is not met within 30 days, the provider-based attestation must be recommended for denial due to missing information per Change Request 2411, issued April 18, 2003. To avoid such a denial and possible payment recoupments you should hold off on submitting the attestation until all information is available.
7. Do I need to submit the CMS form 855 to report the new service location prior to, at the same time, or after the submission of the provider-based attestation.
Preferably the form 855 will be submitted and approved prior to your submission of the provider-based attestation; however they can be submitted simultaneously. We will not be able to complete our review of the provider-based attestation until the CMS Form 855 has been recommended for approval by our Provider Enrollment area.
In addition, if the CMS form 855 has not been submitted by the time we begin review on the provider-based attestation, this will be included in our missing information request letter. As mentioned in #4 above, if requested information is not received within 30 days, the attestation must be recommended for denial.
8. Do I need to reattest or report changes?
Again, the entire attestation process is voluntary. However, if you have previously chosen to go through the attestation process, and have now experienced material changes in the relationship between the hospital and any provider-based facility or organization, such as a change in ownership of the facility or organization or entry into a new or different management contract that could affect the provider-based status of the facility or organization, you may want to consider reporting those changes in the form of an updated attestation statement.
9. What form and/or documentation is required if I choose to go through the attestation process.
There is no officially required form that must be used when providers elect to go through the attestation review process. A provider is allowed to create their own form if they prefer, but it must address the issues discussed in 42 CFR 413.65.
In addition to completing this attestation, documentation that demonstrates that the provider-based requirements have been met, i.e., organizational chart, etc., must be submitted with this request. CMS and the FI/MAC have the discretion to request additional information not listed on the provider-based application in order to further substantiate compliance with 42 CFR §413.65 or §413.174. Any special circumstances should be fully explained in a cover letter with this request.
Although there is no required form, WPS has created a suggested form that can be used. See the main page of this section for this suggested attestation form. This template includes all of the regulatory verbiage, as well as explanations as to what type of documentation that we would need to see regarding that issue. Use of this form, although not required, will assist in ensuring that all necessary documentation was sent in to ensure a quick and accurate review. Note that although the FI/MAC is the first point of contact for reviewing the attestation, we only recommend approval or denial to CMS, who makes the final determination.
Page Last Updated: Tuesday, 29-Dec-2009 13:36:02 CST
