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CMS Final Rule on Provider Enrollment and Ordering and Referring Physicians Makes Provisions for Residents

April 27, 2012—The Centers for Medicare and Medicaid Services (CMS) April 24 posted the final rule, Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Changes.  

This rule finalizes several program integrity provisions of the Affordable Care Act (ACA, P.L. 111-148 and P.L. 111-152). For teaching institutions, one of the most contentious parts of requirements regarding ordering and referring physicians is that Medicare claims could not contain the name of interns or residents who ordered and referred.  The AAMC has been speaking to CMS about this issue over the past several years. 

In the final rule, CMS clarified its position as follows: 

If States allow residents [Note: in this context, “resident” includes “an intern, resident, or fellow who participates in an approved medical residency program”] who have a provisional license, or are otherwise permitted by State law to practice or order and certify services, we will permit them to enroll in Medicare to order and certify, at the direction of their teaching institution. In situations where States do not offer licensure or otherwise permit such individuals to practice or order and certify services, the teaching physician's legal name and NPI must be included on the claim for services. In this latter circumstance, the claims will not be paid unless the ordering and certifying physician, in this case, the teaching physician, is listed on the claim as the ordering or certifying physician.

Other provisions in the final rule include the following requirements: that all providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (NPI) include their NPI on all applications to enroll in the Medicare and Medicaid programs and on all claims for payment submitted under the Medicare and Medicaid programs; and that physicians and other professionals who are permitted to order and certify covered items and services for Medicare beneficiaries be enrolled in Medicare.


Ivy Baer, J.D., M.P.H.
Senior Director and Regulatory Counsel
Telephone: 202-828-0499


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Washington Highlights, a weekly electronic newsletter, features brief updates on the latest legislative and regulatory activities affecting medical schools and teaching hospitals.

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Jason Kleinman
Sr. Legislative Analyst, Govt. Relations
Telephone: 202-903-0806