Taking Action on Medicare Prescriber Enrollment

Jun 21, 2016
Medicare plans need to take action now to ensure a seamless member experience when CMS’ Part D Prescriber Enrollment Program takes effect in 2017.
  • Medicare


380,000. That’s how many prescribers across the country have not yet enrolled as a Medicare-eligible provider with the Centers for Medicare & Medicaid Services (CMS) per the 2014 Part D Prescriber Enrollment program, which requires all health care providers who prescribe medications to Medicare Part D beneficiaries to enroll, or seek an exemption from CMS.

CMS postponed the original start date for the requirement – which is an effort to curb Medicare fraud, waste and abuse – to February 1, 2017. Even with this extra time, given the number of outstanding enrollments, CMS and plan providers are concerned about the impact to patients when the requirement takes effect. If a provider is not enrolled or exempted from the program, the claim for the medication they prescribed could be rejected at the point of sale, leaving patients confused, and more importantly, delaying their access to medication.

CMS has performed outreach to multiple trade associations, visited conferences and even picked up the phone to call 500 prescribers directly.  While there has been some slight improvement, these efforts have not moved the needle enough. To close the gap, CMS is looking to health plans to take action with their in-network prescribers.

Why are prescribers not enrolling?

The most likely reason for the high number of outstanding enrollees is awareness. Generally, physicians know they need to be enrolled with Medicare in order to bill Medicare for services.  However, some medical providers -- such as dentists, nurse practitioners and physician assistants – have not typically needed to enroll with Medicare because their services either are not usually billed to Medicare, or their services may be bundled with a physician’s services. The need to enroll, and the consequence of not enrolling, is not well understood.

What can health plans do?

Outreach efforts to date have not brought the results the industry deems necessary to successfully implement this requirement.  To address this need, Express Scripts has developed three solutions that Medicare health plans can implement to reach unenrolled prescribers.

  • The first pairs targeted prescriber data with our Academic Detailing solution to allow plans to target specific prescriber populations and educate them on key elements of prescriber identification and enrollment. It also includes periodic reporting to allow plans to track progress.
  • The second includes our data-enabled program that allows health plans to identify unenrolled prescribers in their network so the plan can conduct targeted outreach to those prescribers leveraging Express Scripts-created scripting and leave-behind materials.
  • The third provides plans with essential data on prescribers in their network or outside of their network prescribing to their beneficiaries to permit them to perform outreach; with this solution, plans  develop their own scripting and ancillary materials.

In addition to reaching prescribers, plans are encouraged to continue educating their members about this requirement, such as sending letters to inform members who have an unenrolled provider in their record, so they can ask their providers about their enrollment before treatment is prescribed.

Timing is key

In order to ensure that the applications for Medicare enrollment are completed by February 1, 2017, enrollment must be completed no later than December 1, 2016.

The overall goal of this program is to protect the Medicare benefit and keep it affordable and available for all.  A little effort from all Medicare plans can help ensure a seamless implementation next year.

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