Medicare credentialing for the solo physician

have lost much faith in my consultant after having gone through the Medicare credentialing process on my own.  Thank goodness I ended up not using them.  I saved about $2,000, and got my Medicare number a lot sooner than I would have through my consultant.  (Correction: the $4,000 I quoted in my previous post was for the entire insurance credentialing package, including private insurance panels.) The main reason I originally considered using a consultant was because I was afraid of running into delays due to some lame oversight.  I’ve often heard of horror stories of people taking up to a year to get their Medicare number because of all the back and forth that they had to go through to rectify stupid insignificant errors or omissions on their applications.  In fact, one person I  know got his Medicare number only after he had written to his local congressman.  Obviously, his practice suffered much financial turmoil during the months he was seeing patients without a Medicare number.  Because I don’t want to go through anything like that, my goal is to be on Medicare and all private insurance panels prior to opening for business.  I also don’t want to turn away any patient in the beginning just because I can’t take their insurance yet.

Had I used my consultant, they would have gone through the paper application, which, assuming an error-free application, would have taken about 60 days to receive approval.  I don’t think they even knew about the PECOS online application system, which requires 90% of applications to be approved within 45 calendar days.  On top of that, the whole application process was not rocket science, making the $2,000 fee a total rip off.

So, I applied for Medicare myself using the online PECOS (Provider Enrollment Chain and Ownership System) application ( Overall, the process was more or less straightforward, considering that you’re going through a government organization.  Their instructions are at this link which you should read, but this blog post contains more details. All Medicare providers are currently required to be enrolled with PECOS by the way.  Even if you do submit a paper application, your local Medicare contractor will enter your enrollment information into the PECOS system for you.  Having said that, I see absolutely no reason to use the paper application.

For those of you who have gone through the paper application process, you know that this 30 page application can be the most confusing thing ever.  Since the application is designed for all healthcare providers, including nurse practitioners, dentists, opticians, etc, much of it does not apply to physicians.  However, it’s not quite obvious which sections are relevant and which are not. In contrast, the online application is a “smart” application, which guides you through only the relevant sections based on an initial questionaire. Hence, theoretically, you should be less likely to commit errors.

For those of you  in practice, you should already have an individual Provider Transaction Acceess Number (PTAN) or Universal Provider Identification Number (UPIN), depending on when you obtained it.  If you’re going to remain a sole proprietor, I don’t know if you need to do anything other than to change your address.  If you’re moving out of state, you might have to obtain a new Medicare number with your new state’s Medicare contractor.  You’ll want to look into that.

If you choose to practice as a corporation or an LLC, under which you will submit claims, you will definitely need to apply for an organizational Medicare PTAN.  I’m not sure if you’re allowed to bill as an individual if you are a single-owner corporation or LLC.

In order to apply for Medicare, you’ll need the following information:

1. Practice address

2. Type 1 (individual) NPI number

3. Type 2 (organizational) NPI number

4. All state medical license numbers

5. DEA number

6. Employer identification number (EIN)

7. Articles of incorporation (for dates)

8. Billing agency information (if applicable)

I didn’t have to provide information on my postgraduate training, malpractice insurance, or hospital privileges.

If you are going to have an optical shop, you will also need to apply for a Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) number, which I think requires a separate NPI number and possibly even a separate business entity.  Since I won’t be outfitting an optical shop, I couldn’t really tell you what this process involves.

Now, I’ll go over a few tips that might help to clarify certain parts of the application.

In previous posts, I’ve expressed my distrust in the competency and efficiency of government organizations.  Because of this fact, I wanted my initial application submission to be absolutely pristine and error-free.  It’s amazing what kind of stupid things can get your application returned to you, such as not entering the 4 numbers after your zip code.

Having said that, I found a few errors on my application after I had submitted it.  The lesson of the story is, don’t work on your application when you’re tired or sleep-deprived.  In a rush to get my application out, I finished it late at night after I had come back home from a friend’s birthday party.  Thankfully, the mistakes didn’t involve any missing information, so they didn’t come back to haunt me.   I’ll go over where I made my mistakes later in this post.

The online PECOS application FAQ states that you can fix any errors or omissions online that you discover after submission.  However, it’s not as easy as it sounds.  Once you submit your application, you actually won’t be able to revise it immediately.  There is no tab that lets you go back to make changes. You actually have to wait 2 weeks for your Medicare contractor to conduct an initial screening before you can fix any mistakes.  So, do your best to have a completely error free application on the first try.

Pointers for Completing the Online Application

1. When you first get onto the PECOS website, you’ll be asked to login with your NPI user ID.  Although incorporated, we’re still considered individual practitioners, so use your type 1 (individual) NPI user ID and password to login.

2. On the “Applicant Description” section of the initial new applicant questionaire, choose “Sole Owner of a PA, PC, or LLC” if you’re not a sole proprietor.

3. Make sure you enter the correct NPI number for each section.  As an incorporated solo practitioner, you should enter you’re type 1 (individual) NPI number in section 1A item 2, and you should enter your type 2 (organizational) NPI number in sections 4A and 4C.  This is where I screwed up.  I mistakenly entered my individual NPI in section 4C.  I guess the reviewer overlooked this error since I did have my type 2 NPI in section 4A, meaning that I wasn’t missing any relevant information.

Scenario 3 at:

goes over exactly this topic.

Other than these issues, I thought the rest of the application was straightfoward.  The other mistake I  made was with my Illinois medical license expiration date, for which I entered 2012 instead of 2011.  I guess it didn’t matter, since I was applying for Medicare in California.

After my online submission, I was instructed to mail in the following additional forms directly to my local Medicare contractor:

1. Signed statement of certification

2. Signed participating provider agreement

3. Signed EFT authorization form with official letter from bank certifying my account information.

4. Copies of supporting documents

In terms of supporting documents, I submitted the following:

1. California medical license

2. Illinois medical license

3. Medical school diploma

4. Residency and Internship diplomas

5. DEA certificate

6. NPI information face sheets (type 1 and 2) printed from NPI website

7. Articles of Incorporation

8. EIN certificate

9. Naturalization certificate (submitted separately few weeks later after being instructed by reviewer)

On the “Tips for Completing Application” section, which, ironically, was available after I had submitted my online application, the required supporting documents included a business license.  I tried to apply for a business license, but was turned away because construction in my office wasn’t completed yet, and I needed to have a site inspection prior to approval.  So, I just submitted my application without one.  Thankfully, I still got approved, probably because as physicians, our state medical licenses are considered  a business license.  The actual business licenses are probably meant for suppliers, optiticians, hospitals, and other non-practitioners.

Remember, these additional documents MUST be mailed to your local Medicare contractor, and not to CMS (Centers for Medicare & Medicaid Services).  For those of you who don’t know, Medicare claims submissions and payments are not directly processed by CMS.  Instead, they go through private intermediaries, which are different for each state or locale.  For Northern California, we go through Palmetto GBA, which is a wholly owned subsidiary of Blue Cross/Blue Shield of South Carolina (I think).  So, don’t mail these forms directly to CMS. Click on this link for a map telling you who your MAC is m

It’s a bit beyond the scope of this discussion to go over becoming a participating provider vs. a non-participating provier.  You can find plenty of resources online.  Here’s one website that goes over the pros and cons of each option:

I think most practitioners choose to become a participating provider.

To finish off this post, here’s my application timeline:

10/9/10: Online PECOS application submitted and signed forms and supporting documents mailed

10/13/10: Application received by Palmetto GBA

10/22/10: Instructed to fax copy of naturalization certificate

10/29/10: Assigned organizational PTAN (discovered through online application status)

11/8/10: Received official letter with assigned individual PTAN and organizational PTAN

11/29/10: Can start receiving claims payment through EFT

In summary, it took me just under a month to get my Medicare number, which was way beyond my expectations.  Everything probably went so smoothly because I applied during the offseason, where graduating residents and fellows have not yet begun to apply for Medicare.  I was probably lucky too.

Howie’s addendum: my experience was very similar to Ho Sun’s in terms of how fast my application was processed. It took me about six weeks to get my PTAN. One hiccup was that the phone number I listed (a T-Mobile prepaid plan which I later ported to my office line) wasn’t answered when they phoned to verify, so they made me send in a copy of my office lease and presumably verified it.

Yes, even if you are already contracted with Medicare through your group, you do need to go through the entire process again for your new practice as it’s under a different practice and TIN. And every five years you will be required to revalidate your Medicare numbers. Don’t ignore it, it isn’t junk mail.

My final pearl is, if your Medicare application is held up and delaying your opening, contact your local congressman’s constituent services office to get them to help expedite things. A few members of our google group have done this. It works. Same for any issues involving federal governmental programs like not getting paid your meaningful use (previous version of MIPS) bonus.

Most ophthalmologists’ practices are about 50% Medicare. After the $183 deductible is met, medicare pays 80% of the allowed amount and if the patient has a supplement or secondary it will usually pick up the remaining 20% (sometimes with a copay or coinsurance). Even if you are out of network with the insurance company of the supplement, usually they will pay secondary to Medicare.

4 thoughts on “Medicare credentialing for the solo physician

  1. Thank you for this very useful post. I am enrolling to Medicare. The system has requested me information about state license, DEA number and certification number. Do you know what do they mean with certification number? I will appreciate your help.


      • Thank you fore replying and sorry I was not more specific. I am a physician and I am enrolling as a solo practitioner (no employees, no LLC, no laboratory, etc). Medicare provides this information in PECOS:

        “This topic captures information about licenses, certifications and Drug Enforcement Agency (DEA) registration numbers for the applicant. License information is related only to this enrollment. Certification and DEA Registration number information applies to all Medicare enrollments for the applicant.” Then Medicare requests this information:
        “Certification information: state where issued, effective date, expiration/renewal date.”

        I understand the License and DEA requirements, however I am not sure what do they mean with that Certification. Further, I have to fill out that Certification information, it is not optional.


  2. Actually I believe that I found the answer: “The Certification Information section must be completed for Non-Physician
    Practitioners who require certification.” Thank you for replying!


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