Focus on Health System Reform: New Registration Requirements for Billing Agents & Clearinghouses

Physicians who choose to participate in Medicare must enroll with the program in order to submit claims for reimbursement.  Part of the enrollment and re-enrollment application prompts physicians to disclose specific information about any billing agencies that the physician uses to submit claims to Medicare.

As part of a broader effort to reduce fraud and abuse in Medicaid, the Patient Protection and Affordable Care Act prompts each State to require “any agent, clearinghouse, or other alternate payee that submits claims on behalf of a health care provider must register with the State and the Secretary [of U.S. Department of Health and Human Services].”  Sec. 6503.  To clarify, the federal registration will most likely be handled by CMS.

Federal rules detailing this new billing agent registration process and defining the term “alternate payee” have not yet emerged.  In North Carolina, the Division of Medical Assistance is currently working with stakeholder groups, including the North Carolina Medical Society, to identify straightforward options for how this new requirement will be folded into Medicaid.

This provision of the PPACA takes effect January 1, 2011.  However, if legislation is required for the State to implement this provision, then the effective date may be pushed later into 2011.  NCMS will update this article as more information becomes available.


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1 Comment

  • Thomas Kline MD

    Again sophomoric, time consuming, delay ridden
    procedures to catch the “crooks”.

    Now the billers will use this as
    an excuse to raise rates, many pushing
    8% of gross receipts as it is.

    We need to do time, hassle, delay of care,
    delay of business, and cost analysis before
    implementing these high “schoolish” measures
    to “combat fraud”.

    The majority of fraud occurs at the big corporation level and few
    truly criminal outfits (see OIG reports) only a very small fraction is doctors and “billing
    agents” in private practice.

    Crooks can register as billers, too. The real pros can get around these measures with ease.

    The problem with these feel good “measures” is the escalation of the hassle factor, a major reason providers dump Medicare and Medicaid.

    Hassle factor (HF): more important than reimbursement. Every proposal should have
    a HF index number. Cost factor (CF): every
    proposal should have a cost increase index
    number. Effectiveness factor EF: every proposal should have a validity factor – will
    this really work.

    Lastly the value ratio of CF/EF HF = overall
    usefulness index (UI) with cutoffs for go no go.

    Put some numbers, some science to all these
    measures to “combat fraud”. They never stop.
    Most don’t work being too easy to get around.

    It would be interesting to get some law enforcement folks to review these proposals as
    well(EF): “nah that won’t work”, “great idea and why don’t you….”

    thomas kline md