Strengthening Medicare Provider Enrollment Screening

Medicare has long had screenings for address verification and site visits, however, an update in their screening processes will put more emphasis on these screening methods.  CMS will also implement a policy to inactivate providers who have not billed the program in more than 13 months.

The Affordable Care Act provided CMS with the authority to enhance security measures in the enrollment process.  A recent GAO study evaluated four specific areas of the screening process and identified two areas of weakness in the current system.  The first is verification of provider location address and the second is physician licensure status.  This most recent announcement from CMS relates to measures that strengthen the process of identifying invalid provider location addresses during the enrolling process as well as ongoing monitoring for invalid, vacant, and mail drop addresses on provider enrollment records.  CMS is implementing four tactics to strengthen strategies designed to reinforce provider and supplier screening activities.

Increase the number of site visits to Medicare-enrolled providers and suppliers.

A site visit has long been part of the Medicare provider and supplier enrollment process for certain high risk category providers and suppliers.  CMS now plans to increase the number of site visits in order to ensure compliance with Medicare enrollment regulations.  While CMS has the authority to require a site visit for any enrolling or enrolled provider or supplier, the increase of site visits will focus on high reimbursement providers and suppliers as well as those located in a high risk geographic area.  The increased site visits are designed to identify provider location addresses that are invalid for any reason or can also reveal with a provider or supplier has not updated their provider enrollment record as required.

Enhanced address verification software in PECOS

Starting this year, CMS will replace the current PECOS address verification software with new software that includes Delivery Point Verification (DPV) in addition to the existing functionality. This new DPV functionality will flag addresses that may be vacant, Commercial Mail Reporting Agencies (CMRAs) or invalid addresses. In most cases, CMRAs are not permitted in the Medicare program. These verifications will take place during the application submission process and may trigger additional ad hoc site visits.

Deactivate providers and suppliers that have not billed Medicare in the last 13 months

Beginning March 2016 CMS will identify providers or suppliers that have not billed Medicare in the last 13 months.  Those meeting specific conditions will have their billing privileges deactivated.  The deactivation of these providers will remove potentially invalid location addresses without requiring a site visit to determine the validity of the location.  These screenings will include specific criteria that exclude providers enrolled solely to order, refer, and prescribe, and certain provider types such as pediatricians, dentists, mass immunizers.

Continuous monitoring of potentially invalid addresses

CMS has started to continuously monitor and identify addresses that may have become vacant or non-operational after initial enrollment. This monitoring is done through monthly data analysis that validates provider and supplier enrollment practice location addresses against the U.S. Postal Service address verification database.  A validation flag may result in a letter to the provider or supplier requiring immediate update to their enrollment record, deactivation of billing privileges, or a site visit for verification.

Every provider or supplier enrolling in the Medicare program is required to submit accurate practice location address information on their application.  Medicare Administrative Contractors (MACs) processing enrollment applications will, with increasing accuracy, identify improper location addresses.  Providers attempting to enroll using a home address, a vacant building address, an address where you are not actually practicing, an address under construction, or a mail drop address will be increasingly identified as Medicare strengthens its screening processes.  The importance of maintaining your enrollment record with address updates has also become a high priority to ensure against the possibility of having your billing privileges deactivated.

About nCred

nCred is a leading national provider of healthcare credentialing services.  nCred has assisted thousands of providers and healthcare organizations throughout the country with the payer provider enrollment process.  The successful implementation of leading technologies combined with experienced credentialing staff produce excellent results for nCred clients.  Contact us today at (423) 443-4525 or fill out our request for information form to discuss how our services can benefit your organization.