Medicare Application by the Numbers: Pharmacy Compliance Guide Summary
Applying for a Medicare number, also known as PTAN, can be time-consuming, confusing and quite daunting as there are almost 50 pages in the CMS 855B alone! First, you need to determine which application needs completed based on the services you hope to offer. Then the next challenge is to determine which sections need completed. Are there additional forms to complete, what extra documents need included, how and where to submit payment? Then the longest part, waiting to see if you have been approved or denied!
Let’s start by clarifying the differences between the applications. The two most common CMS applications are the CMS 855S and CMS 855B. The 855S is used if you intend to bill for non-accredited drugs and/or DME products while the 855B can be used for billing immunizations. These applications are actually processed by various contractors of Medicare. All CMS 855S applications are processed by National Supplier Clearinghouse (NSC). The 855B applications are processed by 7 different regional contractors based on your state.
While the applications require some related information, the only true similarity is the price. Regardless of the state, practice, or application type, the current cost in 2018 to submit an application is $569 payable via PECOS. A few differences to keep in mind, the 855S may require owners/managers to get fingerprinted and certain documents must accompany your application including a Certificate of Liability with the certificate holder listed as NSC and a Surety Bond for $50,000 coverage. If accredited you would also need a certificate of accreditation and a Certificate of Liability with the accreditation organization as the certificate holder. The 855B does not require these items. The 855S gives you the option to accept or not accept assignment-this is a big decision and should be discussed with your billing person. However, with the 855B you have to accept assignment. Prepare to wait 2-3 months for the 855B and 3-4 months for the 855S.
People often ask if they can have a PTAN without being accredited. The answer is yes, if you plan to bill only non-accredited drugs; use the 855S. By doing so you would be able to bill Medicare for: Epoetin, Immunosuppressive Drugs, Infusion Drugs, Nebulizer Drugs, Oral Anticancer and Oral Antiemetic Drugs. Once you are assigned a PTAN for non-accredited drugs, you may consider applying for accreditation to offer DME products. This would require another application and to be accredited by one of the nine accreditation organizations such as BOC, ACHC, and The Compliance Team.
Regardless of doing the application on your own or using a specialist to help with the process, there is always a risk your application will be rejected because a page was omitted, a box was not checked, a date was missing, or the wrong color ink was used. If you ever get a request from Medicare-answer immediately, as there is only a small window of time that you can submit requested information or the application will be rejected. Please keep in mind, if this happens, you have to pay the application fee of $569 and start the process again.
If you are feeling overwhelmed or even just slightly apprehensive about tackling a new application, a re-validation request, or you're trying to reactivate your PTAN, consider R.J. Hedges & Associates Medicare Application Team! Historically, this was a service we only provided to our customers, but with so many pharmacy owners needing help, we are pleased to now offer a Medicare Application Preparation Service.
Rather than researching "how to complete a Medicare Application" you can complete our web based questionnaire. Our experienced and knowledgeable staff will tailor an application for your location. We will complete the Medicare application and send you a version the will only need signatures and PECOS payment prior to submitting to the Medicare contractor in a prepaid envelope.
Todd – Hey Pharmacy podcast nation, this is Todd Urey part of the pharmacy podcast network has a very interesting segment within a segment. We promised you to always deliver some good content about compliancy. The pharmacy compliance guide has been a podcast segment of the pharmacy podcast network for quite some time. However, we do not believe in standing still, the grass does not grow beneath our feet and with that we are launching a new segment within the pharmacy compliance guide part of the RJHedges team. I want to introduce to the team if you don’t know her already, Jenny Schell. She is part of the RJHedges team. She is a senior compliance strategist and this is her new segment. So Jenny, welcome to your own show.
Jenny – Well thank you Todd, I’m rather excited. I can’t wait to see where this takes us and what all conversations we’ll be having in the future but I’m super excited to be on with you.
Todd – I am too and I guess first of all, we do have somebody in the room with us that’s being interestingly and not much like his personality – quiet. Cause he’s not a quiet individual so I want you to introduce our guest.
Jenny – I have my friend Mr. Ainsley on the phone with us. Ainsley has a pharmacy in Delaware and Ainsley has been working with RJHedges since about 2014 and he has become a very good friend of mine. I absolutely adore him. He has a wonderful family with a wife Rachel who is just a hoot. Ainsley and I have just been getting along for awhile and we bounce a lot of ideas off of each other so I thought he would be a fun person to bring on for my first segment of the podcast.
Todd – Mr. Ainsely, welcome.
Ainsley – Thank you, it’s truly an honor to be part of this inaugural podcast and we’ll have some fun tonight and hopefully we’ll you listeners really engaged.
Jenny – Let’s hope!
Todd – So first of all, Jenny & I are Steelers fans and the great city of Philadelphia captured the Super Bowl this year. So are you an Eagle’s fan over there?
Ainsely – I’m sad to say I am not an Eagles fan. I don’t even follow American football. I follow Rio Madrid & Spain soccer I’m a die hard real Madrid fan. If anyone comes to my basement they will know I am. But I feel happy for the city of Philadelphia.
Todd – Well, tell us about your pharmacy over in Wilmington Delaware.
Ainsely – We have a small Mom & Pop store. My wife is the CEO of the company. I am the face of the company, we have 4 employees, 1 other pharmacist and 2 other technicians and I have a delivery driver. We have a small pharmacy and I’m very much engaged in our community. We do lots of charities. We help with, if anyone know Wilmington Delaware, we are considered one of the more, how shall I put this in a nice way. It is a very dangerous city. We have at least one fatal shooting a day. So we are part of a dangerous community but we’ve also taken up the mantle of trying to help that problem by doing a lot of charity work and trying to be peacemakers in our small, little community. That’s our claim to fame.
Todd – Jenny, what are we talking about in this first episode? Cause I know you brought Ainsley here for a very specific reason and I want you to kick this off for us.
Jenny – I wanted to talk tonight about Medicare and the different types of Medicare applications there are. It’s something I get asked about all the time because there seems to be a lot of confusion in what Medicare application they need to fill out. If they want to do immunizations, what application do they need to do? Is that the same as if they want to do accreditation and do non-accredited drugs? I thought this would be a really good way to start out because I think there’s a lot of room to expand the knowledge base out there so that people really understand. With Medicare there are more options out there than most people think. And I thought Ainsley would be a great one to talk to because we’ve helped Ainsely with both his CMS855S application so that he has his Medicare number that he is able to bill for non-accredited drugs as well as DME items. So he is accredited and we’ve also helped him with the CMS855B application. And that application is what you do for immunizations. So I thought he would be a good one to come on and talk about his experience and the importance of having the medicare numbers in his store. And how we have been able to help him get through the process.
Todd – So Ainsely, from your prospective, I want you throw your hat in the ring and give us what this all looks like from your side.
Ainsley – Let me start off by saying in 2014 when I met Jenny and the RJHedges team, we had just started, our pharmacy was a year old. We had a few consistent customers but we wanted to expand. We wanted to be able to capture a bigger market. I talked to Jenny, I talked to her dad and what we discovered was if I get Medicare accreditation, I could be able to do things like walkers and bill for immunizations. I thought to myself “that’s a good idea”. I called my wife on the phone while I was at this conference where we met and she said “go for it if you think this is what we can manage”. I spoke to Jenny, Becky and Amy and they all agreed this is what we need to do. And they got together, at the conference, and we signed up and we spoke to someone from BOC who was at the booth next door. It was almost an instantaneous click.
Jenny – I can’t believe you remember all the details Ainsley. I’m rather impressed! You remember every single one of us that was at the booth. Fantastic!
Ainsley – Actually the lady from BOC, was Wendy. We got together, we sat down and I signed up with both of them at the same time. I went home and thought this will take a long time until anybody calls me. The next week Amy calls me. We start the process, we get all the documents that they wanted. I quickly put all the documents together, faxed it off and they started the process.
Jenny – I’m gonna interrupt you there, Ainsley. You did such a great job getting us that information quickly because the key with Medicare is they take forever to process the application. You were able to get us the information needed in order to complete that 855S application. The 855S, we filled that application out, it goes to National Supplier Clearinghouse (NSC) and there’s specific documents that have to go with it. We always like getting that information from our clients as fast as we can so that we can get the application completed in it’s entirety and back to the client so they can double check, sign and submit it. Because NSC takes roughly 3 months to process that application. They are now doing fingerprinting. Ainsley, did they do fingerprinting back then on you?
Ainsley – No.
Jenny – You lucked out!
Ainsely – Actually what they did is checked the Federal database. And because my fingerprints were on the Federal database, I did not need to get them.
Jenny – So you were one of the lucky people because it only took 3 months and if you don’t have your fingerprints, it can take 4.
Ainsley – Yes. And what they did is NSC came to the store as well as BOC and they did their inspection and because I signed up with RJHedges, I had all my documents in the store, on hand. I would say both inspections did not take an hour. They took maybe 20 minutes each. As a result, after my inspections, within that month, I was able to get my documentation. I would say the whole process, starting in March I had my documentation by summer ready for the new flu season.
Jenny – Well that was a different application Aisnley. We completed the 855B. That one is for your immunizations.
Ainsley – We filled both out at the same time.
Jenny – Correct because you were the one of the ones, like most pharmacists out there, you were confused on the difference between the two applications.
Ainsley – That’s right. I had no idea there were so many different forms.
Jenny – Exactly! And there are different ways to go about getting Medicare numbers. It’s important to look at what you are trying to do. Because in your case, we wanted you to get 2 different numbers. We wanted you to have that Medicare number so that you could bill for the DME items and for non-accredited drugs. But we also wanted you to have that immunization PTAN so that you would be able to take off with your immunization program in the fall and to be able to bill for flu shots. And the beauty with completing the 855B is that application actually goes to the regional office. They don’t take nearly as long as NSC. Typically, not flu season, when you process that application, it only takes about 6 weeks or so. It doesn’t take nearly as long. Two different applications but you do have to pay the fees for each. I know for 2018 the fees for this year they are $569 per application. It’s important to note that every single year Medicare raises the price. Sometimes it’s only by $9, sometimes it’s by 20. You never what the fee is going to be. It’s important to know when you’re going into Medicare and you’re looking at what numbers are going to be best for my store that you realize that you’re going to have that application to fill out and you’re going to have to pay that fee through the PECOS system. We walked you through all of the right steps so you didn’t have to worry about it. Right, Ainsley?
Ainsley – Actually, you all did one better. I gave Amy my credit card and she did my transaction.
Jenny – So she did the paperwork for you on PECOS. Literally, all you had to do was sign the application and mail it.
Ainsley – Yes, that’s right. Sign and mail. You all sent me the envelope to mail!
Jenny - We did. I think we even put the postage stamp on it so you wouldn’t forget. We sent a blue pen because they’re sticklers. They like blue ink when it comes to signatures. If you are filling out a Medicare application, a revalidation, anything with Medicare please make sure that you’re using a blue pen so that you don’t get something back from the lovely folks at Medicare saying “DENIED, wrong color ink.
Todd – That’s crazy!
Ainsley – One thing your listeners should know if they try to fill out the form on their own and they get rejected, they have to sign up a form again and they will have to pay the $569 twice.
Jenny – Well, they give you so much time. If you do an application and it gets rejected, you have so much time to put it back in and see if they like your application or not. But Medicare, I always say there is a special place in heaven for those that work in Medicare because well, you never get the same answer no matter who you talk to at Medicare. But they’re just a pain in the butt. And that Medicare application 855B, let’s see, how many gosh darn pages is that? It’s a whopping 48 pages that you have to figure out what pages you have to fill out, where you’re supposed to sign and what you’re doing. And that’s one of the beauties with our clients. We’re able to do this application for our clients and we’re really excited to announce we’re actually branching out. We are going to have a service just for completing a Medicare application. So you guys out there, if you feel so overwhelmed by these stupid Medicare applications and the revalidations and you feel like you’re just throwing your hands up in the air and saying “Oh my gosh. I can’t handle this anymore. Why is Medicare doing this to me?” Just contact us at RJHedges.com. We are going to be able to do these applications for folks now for just $500 and we’ll get it all done. Because if you look at these applications, they are extremely daunting because they are so long and Medicare has it set up that it’s like a “one size fits all” they think for these application. So we’re in the world of independency. We think pharmacy right? Well when you look at these applications, they are for everybody. They can be for your ambulance service. It can be laboratories. It can be for anybody really out there. There are all different divisions of healthcare industry that would fill out this application. So knowing what and what sections you have to fill out is so important and knowing which application to fill out is so important. To recap real quick 855B, B as in blood, is for your immunizations. If you guys out there want to get an immunization PTAN number, go for it. It’s fantastic to have . I’m a huge advocate for offering immunizations in your pharmacy. It’s a great service to offer your clients and 855B completed you will be what is called, you have to accept assignment. You will be accepting assignment if you bill Medicare for immunizations. What that means is immunizations Medicare requires you to accept assignments so that means Medicare is going to pay you the pharmacy. You pay directly. When you deal with the other division of Medicare, that 855S down at NSC, you have the option of accepting assignment or not accepting assignment. So that means you can bill Medicare directly which I would say shouldn’t be you don’t accept assignment and you’re just telling your patients “this is the price, you pay us and then you can submit it to Medicare”. I’m not a huge fan of that because I feel with my life being busy with the kids, I would have to say no I have to have everything done right there and then. I have a lot of clients that don’t accept assignment but here is the kicker for you folks….if you don’t have a PTAN number for immunizations so you’re already accepting assignment for that. You have to accept assignment for your 855S application so there’s no confusion there. So if you don’t do immunizations, you can have the option of “do I accept assignment, do I not accept assignment?” But if you do bill immunizations, you have to take assignments.
Ainsley – Here’s what it is…if you’re doing immunization, you have to accept assignment. If you’re not doing immunization you don’t have to accept.
Jenny – Ainsley, you just summed it up wonderfully, without so much work. See, this is why I keep you around. He’s my other sales person.
Ainsley – If you see us at a conference, I’m usually at the booth. One of the things I would like to say about the assignment, not only assignment, when you sign up with RJHedges as well, you also have the option to find companies that will assist you once you have your PTAN number to do your immunizations, to do your DMEs, to help you with your billing process. It’s no good to have the numbers and you can’t bill because you don’t know who to bill to or it’s difficult to figure out how to bill. You can get assistance with RJHedges.
Jenny – That’s because we do have clients all across the country and we talk to them all the time. We hear feedback from them on who they like to work with and who they don’t like working with. That helps us tremendously when NSC? that’s opening. Knowing who I can say is a good company to work with for billing. Perfect example…there’s a company called TransAct Rx they specialize in immunization billing. We will send people over to them because we’ve noticed that pharmacists are fantastic at doing immunizations. You guys pretty much stink horribly at the billing process. We try to find companies that are working well with our clients and that we feel comfortable recommending. We won’t recommend a ton of companies because that can get a little sticky because you have one client that had a great experience then you have another client who had a horrible experience. You know how that is, it’s like a car. Should I go for a Ford today or should I go with a Dodge? That’s why we don’t get too much into who is the best company for billing but we will give you ideas. Or just hook you up with another one of our clients that you can just talk to. For example – I can call Ainsley and say “hey, I have a pharmacist who is looking at doing DME. Can you help him figure out who to use for the DME billing ?” And guess what? Good ole Ainsley down there will be more than happy to take the call because he loves me. And he takes that call, helps that pharmacist out and gives him some pointers. It’s a really great relationship there.
Ainsley – From our prospective, when you go to a clinic and you have all this stuff and you have to bill, let’s say 20 patients or 30 patients, and on a really good day you have 200 patients whom you just given immunizations to and you’re stressed out about these patients and how do you bill for them. It becomes easy when you have a company that you’re dealing with like in our case TransAct RX and RJHedges. RJHedges basically told us “deal with TransActRX” as an option. And we called them and they made life so easy. What they do is they also teach your technician how to bill for an immunization. Another company is EasyDME. EasyDME teaches your technician how to bill for a DME product and they’ll advise you. They will tell you what products will help your business to grow. They will tell you if you want to bill a walker, a rollater(?), this is how you go about billing a rollater(?). They walk you through the steps very easily. They have staff that is well trained in walking pharmacists and pharmacist staff who are not trained in doing this on a daily basis in order to become proficient on a daily basis. And it makes life so much easier for a pharmacist knowing he can pick up the phone and say “I just got a script for a pair of stockings or shoes. What do I do?” And you feel so confident that you just want to do another one right after. It’s that level of confidence that helps when you have companies backing you that are in your corner. And somebody comes in and asks you “do you have so and so form?” yes I have that form because I’m with RJHedges and they have provided me with all or I can call and she can walk you through how to fill out a form for a pair of shoes so you bill the shoes properly. And now you can fit the pair of shoes and you have the documentation. God forbid someone comes in and asks about a pair of shoes. So you have the documentation, you have everything in a file and everybody is happy. And that’s the kind of confidence the kind of company like RJHedges provides for their patients and their clients.
Jenny – Because we want to make sure you have all the tools to be as successful as possible because there are so many possibilities out there for pharmacies to increase their business and help patients. You just have to figure out what your niche is. If your niche is dealing with Medicare, then let’s figure it out. Let’s find out what division….
Ainsley – Even if it’s not your niche, even if you just want to figure our foot traffic, it’s good to have in your corner. Even if you’re not going to do a 100 of them. Let’s say a 100 rollaters(?) in a year where you may not make your money back from the investment you made to have but what it will do is increase your foot traffic into your store so that one patient can see what other services you offer. She may fill her prescriptions with you, she may buy vitamins from you. There are so many services that you may provide her that just coming in to buy a rollater(?) from Medicare.
Jenny – I forgot to mention earlier, was when we were talking about Medicare. Ainsley took advantage of becoming accredited. But accreditation is not always the right fit for everyone. A lot of people ask me if you can have a Medicare number and not be accredited. And yes, you can have a Medicare number and not be accredited. There is a spot on your 855S application that asks if you are going to apply for a number for non-accredited drugs. Guess what non-accredited drugs means no accreditation is needed. You can get a Medicare number, bill for drugs like Albuterol what everyone wants to be billing for because there is a need. You can bill for anti-rejection medicines, cancer medicines, things like that. There’s a list of 6 different things on an application that specifically says non-accredited drugs. You can go ahead and get a Medicare application and you don’t have to get accredited. Because again, dealing with DME items, that is not for everybody. Having the ability to be able to bill Medicare for those breathing treatments, that’s fantastic. When you’re looking at completing an 855S application, a couple of things you need to have in place when you submit that application is, you have to have a Surety Bond. You need to have one of those in place for $50,000 in coverage. The key to that is it should only cost you about $250 but if you have some skeletons in the closet, it will cost you more. You also have to have your Certificate of Liability in place and you need to have it with the certificate holder with NSC’s information. You need to have that if you’re going for the drugs or you’re going for accreditation. That is important. If you’re going for accreditation, you will also need to have a copy of your Certificate of Liability with your accrediting organization as your certificate holder. There’s 9 different accrediting organization out there. I like working with BOC. If you choose BOC, great. If not, hey that’s fine. There’s HQAA, there’s the Compliance Team, there’s ABC, the lovely Joint Commission, the list goes on and on. Those are 2 documents that you will need to have in place when filling out that application. Whether you fill out that application on your own and submit it or us at RJHedges complete it for you, we have to have those in order to submit it to Medicare or Medicare will kick it back. They have to have that documentation to make sure you’re legit. Again, 2 very easy documents to get a hold of. It won’t take you long.
Todd – If I were a pharmacy owner and I had the need for accreditation and compliancy, I would walk over to my web browser and I would type in RJHedges and Associates and I could hear for the rest of the time I’m not having to worry about it. I think there’s a component to this that we need to press the button RJHedges and that’s it. Just press the button and walk away.
Jenny – I think we could have another podcast on just the benefits of accreditation and the process of it. Because that’s a whole other can of worms that I get a ton of questions on. We’ll save that for another time. Those all things you need to consider when you’re dealing with the world of Medicare.
Ainsley – Accreditation is becoming so important.
Jenny – Many people would say that accreditation is so NOT important because it’s a pain in the tush.
Ainsley – It might be a pain in the tush, but very important if you want to bill for any drug. If you want to bill for HIV drugs it’s becoming very, very important.
Jenny – I think honestly that accreditation, in a whole, is going to become a requirement in time. Because look at the insurance companies. The insurance companies are just getting crazy with all of their requirements. I think the pharmacy accreditation aspect is going to be coming down the road. I thought that 2 years ago but who knows? The insurance companies are still being crazy. There’s still no requirement, per se, for pharmacy accreditation. We are seeing more insurance companies and states requiring accreditation to participate in Medicare programs.
Ainsley – Yes. That’s exactly what it is. In order, in the state of Delaware, if you want to bill for HIV drugs for a Medicade patient, you have to be accredited. Fortunately for me I was already accredited by BOC.
Jenny – You were on top of it before you needed to be on top of it Ainsley.
Ainsley – Because I have a team like RJHedges.
Todd – I thank Ainsley for being an amazing guest tonight. You are going to have to come back. Jenny, you obviously kicked off a meaningful show and component of the pharmacy compliance guide. I’m very excited about the new segment.
Jenny – I’m hoping to bring some other topics and other awesome guests to the show.