6 Tips To Handle Medicare Enrollment And Revalidation - DoctorsManagement 6 Tips To Handle Medicare Enrollment And Revalidation - DoctorsManagement

6 Tips To Handle Medicare Enrollment And Revalidation

By  Grant Huang, CPC, CPMA

CMS has recently beefed up its efforts to conduct random site visits to ensure that enrolled providers and suppliers aren’t actually storefronts engaged in fraudulent billing. Unfortunately, many practices and providers have gotten caught up in these efforts, making the already unforgiving enrollment and revalidation process even more punishing when mistakes happen.

Even so, CMS needs to do more to combat Medicare fraud, according to a report by the Government Accountability Office (GAO). “The GAO analysis identified areas for improvement in our Provider Enrollment Chain and Ownership System (PECOS) regarding verification of provider and supplier practice locations and physician licensure statuses,” CMS writes in a Feb. 22 press release. “The GAO’s findings supported CMS’ efforts to further enhance provider and supplier screening activities. CMS has begun increasing site visits to Medicare-enrolled providers and suppliers, enhancing and improving IT systems and implementing continuous data monitoring practices to help make sure practice location data is accurate and in compliance with enrollment requirements.”

The release listed four specific steps CMS is currently taking in response to the GAO report that will crack down on Medicare fraud with respect to enrollment and billing:

Increasing site visits to providers and suppliers already enrolled in Medicare (including those needing revalidation), using its site visit contractor (visits performed by individuals employed by a private firm).

Using its online PECOS system to “better detect vacant or invalid addresses or commercial mail reporting agencies.”

Analyzing enrollment data to identify and deactivate providers or suppliers “meeting specific criteria that have not billed Medicare in the last 13 months.”

Monitoring addresses of enrolled, enrolling, and revalidating providers and suppliers each month, checking against U.S. Postal Service databases to weed out invalid addresses.

To help you with these complex processes, The Business of Medicine spoke to several orthopaedic groups who have recently undergone new provider enrollments and revalidations.

New provider enrollment

Having plenty of lead time is crucial, says Don Schreiner, MBA, CEO of OrthoIllinois in Rockford, Ill. He regularly tells all new hires that it “may take up to 120 days” to get them to their start date – a habit that he finally took to heart after his credentialing staff trained him repeatedly, Schreiner jokes.

  1. Lead time and documentation. New providers without national provider identifiers (NPIs) must first apply for an NPI, a process that can take up to four weeks, and requires the individual’s diploma, state licensure documentation, and even school transcripts to expedite, says Leslie Elmer, CPCS, credentialing coordinator at OrthoIllinois.
  2. Use online PECOS for more speed. Medicare offers a web-based system for managing new provider enrollments, existing revalidations, reassignments, and any other enrollment information called PECOS – the Provider Enrollment Chain Ownership System mentioned above in the press release. When Elmer switched from paper CMS-855 application forms to online PECOS, she noticed every process ran faster, often by a week or more.
  3. Don’t be afraid to call, and be persistent. Despite her preparations and lead time, Elmer does run into problems with individual applications, and her advice is to call whenever you find yourself in that situation. “You have to be your own best advocate and call CMS, wait if you have to, but call and explain the details to a live person,” she says. Tip: It’s best to call your specific CMS carrier rather than your CMS regional office, which will typically refer you to your carrier unless you’ve already spoken to them and need to escalate.
  4. Retroactive billing is always an option. In the worst-case scenario, you have a provider starting work without billing privileges, but that doesn’t mean he or she simply sits around. You can retroactively bill back to the application date on a successful Medicare enrollment application, and suffer no negative consequences other than a slight delay in payment.


Durable medical equipment (DME) suppliers have the hardest time with revalidation since CMS has classified them as a high-risk provider type.

  1. Get the address right. In one case, revalidation letters were sent to a provider’s old address – to a physician’s address when she was still a fellow, says Christy Owen, revenue cycle manager at Advanced Orthopaedics Sports Medicine in Houston. In another case, a P.O. box was left off of the DME application, which resulted in frozen payments and $15,000 held up, Owen says. These were both situations that required escalating to CMS. Having the address correct, down to the most precise punctuation of names, is crucial since corrections restart the waiting process for a response.
  2. Signage at office locations. CMS on-site inspectors visited a satellite office of Alabama Orthopaedic Specialists PA, but visited the wrong address, resulting in revocation of billing privileges, says Ron O’Neal, MPH, FACHE, administrator. He had to send photos of the correct office to get CMS to repeat the site visit, at which point the inspectors informed him that his signage required correction. It didn’t say that the location was “by appointment only,” so this had to be added. It’s important your signage is totally clear about office hours, O’Neal says.

Satellite offices that have variable hours have proven to be a very tough nut to crack when it comes to random site visits, O’Neal says. CMS doesn’t want to call ahead since this would make the visit not random. There’s no easy answer for this, but it may require escalation to your CMS regional office.

Grant Huang, CPC, CPMA (ghuang@drsmgmt.com). The author is Director of Content at DoctorsManagement.

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