PT Classroom - Medicare Provider Enrollment: Choosing the Best Option ׀ by Jodi Czernejewski MS/CCC


Ms. Czernejewski is the CEO and founder of Advanced Institute of Healthcare, Advanced institute of Rehabilitation Services and Advanced Institute for Senior Care. She has over 26 years of experience in healthcare and has managed multi-state operations in excess of $70M in the venues of hospitals, skilled nursing, outpatient, home health and physician practices. Through her consulting company Advanced Institute of Healthcare she provides strategic guidance to both local and national healthcare entities. For additional information you may email her at;

Medicare Provider Enrollment: Choosing the Best Option

Medicare is a very complex system consisting of a plethora of manuals, transmittals and regulations. Weaving through the maze can be difficult. However, this complexity also brings variety that can lend to opportunity and business strategy when completing your Medicare provider enrollment. One of the things to be mindful of is that healthcare practitioners have options when wanting to enroll under Medicare to bill Medicare recipients for services. Participating in the Medicare program as a “Provider”; allows you to bill Medicare for services. It also means you are willing to accept “Medicare assignment” (accepting Medicare’s designated fee schedule) for those services. You have a few options to consider before initiating the application process. Here’s a brief overview of options:

1. Enrollment as a Physician or Non-Physician Provider (CMS-855I Application): this application is used by individual Physician or Non-Physician Providers (which includes Physical therapist In Private Practice; often referred to as PTIP). This process allows many individual practitioners to enroll as a provider.

2. Enrollment as a Clinic/Group Practice (CMS-855B Application): this application is used by Group Practice Providers (GPP’s) or other organizational suppliers. Multiple practitioners working together as a group, includes Physical Therapists. This can be a cost effective way for several practitioners to consolidate their resources for group bargaining power and lower overhead.

3. Enrollment as an Institutional Provider (CMS-855A-application): this application is used by institutions who meet specific criteria to bill as an institution. This includes Outpatient Physical Therapy/Occupational Therapy/Speech Pathology Services. This option can provide a structure for multiple disciplines or professionals who are working together to grow across a larger geographic radius and consolidate resources to create a more comprehensive program.


When considering what is the best option for your practice there are some key factors and questions you will want to ask. While this listing may not constitute all of your key variables it will provide you with a good baseline to initiate your decision making process.

Regulatory: The regulatory considerations are different for the various provider applications. Each type of provider type comes with its own set of regulatory chapters both on a federal and a state level. Even though Medicare is writing the national regulatory guidelines, the state (DHHS- Department of Health and Human Services) will enforce those through their survey process as will the Fiscal Intermediary (FI) in their Local Coverage Determinations (LCD’s). You will need to be aware of all of these when choosing. Here are some samples of variations in the different enrollments.
   o Rehab Agencies are considered Part A providers because they fall under the category of institutional providers but when therapy is involved outpatient regulations for services apply since separate guidelines are not written.
   o PTIP’s require direct line of sight supervision between a PT and a PTA meaning the PT would need to be within sight at all times. On the other hand, a Rehab Agency requires direct access to supervision but not direct line of sight meaning the PT could be off site as long as the PTA can gain immediate access for supervision if needed. Keep in mind this can also be influenced by the state practice act which can change stringency accordingly.
   o Geography- A PTIP will typically enroll for a particular location/clinic where a Rehab Agency or GPP may enroll for a series of clinics or locations. In a Rehab Agency the first location is the primary site and other locations are often considered extension sites. A Rehab Agency can actually broadcast an entire state. This allows you to consolidate operations at one location while still having the ability to grow additional locationswithout extensive overhead.
   o Credentialing- is another variation of enrollment. For PTIP and GPP’s there are a series of steps and a wait time in the credentialing process for each new practitioner. For a Rehab Agency because you are enrolling as an institution this process involves fewer steps and an expedited credentialing since the umbrella structure is different.

Clinical- Clinical programming is another determining factor of choice. PTIP’s and providers within a GPP’s often have direct oversight of one or a small number of locations that can create an ease of oversight. GPP’s can have many operational variations among them from clinic to clinic. If you are considering comprehensive programming or specialty clinical programming with multiple disciplines/providers you may want to look at a Rehab Agency since it requires coordination of care on behalf of the patient regardless of locations. Processes and systems are uniformly structured so that practitioners follow the same clinical operations across locations.

Quality—Quality regulations will vary as well. Since the survey process is different for each type of provider the requirement of quality standards vary as well. For instance, a Rehab Agency will require an on-site survey that is one or more days to review a number of safety and quality standards which are more involved than an individual clinic survey. However, Rehab Agency extension site surveys are more abbreviated and you can often complete more than one in a day depending on geography. Rehab Agencies also require a Professional Advisory Committee (PAC) so if you are looking for higher quality standards this will provide you with organizational structure for guidance.

Billing—Is also different depending on what type of provider enrollment you choose. PTIP’s and GPP’s bill differently than Rehab Agencies (Institutional Providers). PTIP’s and GPP’s bill on 1500 outpatient claim forms while Rehab Agencies bill under Institutional claim forms or UB’s. You will want to ensure your billing entity is knowledgeable for the enrollment you choose.

Timing- Is another good variable to consider. Once your application process is complete that is just the first step. You also have to complete the survey process which is executed by the state (DHHS). Since there is an increased demand in each state and a shortage of surveyors the wait time can vary by state from weeks, months and sometimes well over a year. One way to overcome this especially for a Rehab Agency is to use an Accrediting Body that can conduct and complete your survey on behalf of the state. This will not only expedite your process but will also provide you with a higher level quality standard and stamp of approval. It does however, come at an additional cost ranging from a few thousand dollars to several thousand dollars depending on how many staff you have.

While this is a finite number of considerations it is a good baseline platform to help facilitate and formulate your overall strategy. As you develop your short term and long range goals consider the options that can assist you in execution of your overall business plan.

Last revised: June 24, 2013
by Jodi Czernejewski MS/CCC

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