In March 2012, the Centers for Medicare & Medicaid Services (CMS) enhanced its Medicare enrollment screening for new and existing enrollees to the Medicare program. Providers not meeting CMS’s enhanced enrollment screening risk denial, revocation, or deactivation of Medicare billing privileges.

On April 27, 2016, the Office of Inspector General (OIG) issued a report analyzing the early implementation results of the enhanced enrollment screening. In its report, “Enhanced Enrollment Screening of Medicare Providers,” the OIG compared data on enrollment and revalidation applications from March 25, 2010 through March 24, 2011 (the year before the implementation of the enhanced procedures) and from March 25, 2012 through March 24, 2013 (the year after implementation). As discussed below, the OIG found that, since the implementation of enhanced enrollment screening, there has been a substantial increase in the volume of revocations and deactivations of existing providers’ billing privileges. OIG also recommended several additional steps for CMS to take in implementing the enhanced enrollment screening process.

Background

CMS’s enhanced enrollment screening tools are intended to prevent fraudulent or illegitimate providers from enrolling as providers in the Medicare program, and also to ensure accurate revalidation of existing provider enrollees. CMS’s anti-fraud tools include placing providers in risk categories for increasing levels of scrutiny, increasing site visits to high-risk providers, requiring fingerprinting, implementing an Automated Provider Screening system, and denying enrollment to providers whose owners have unresolved overpayments.

Specifically, CMS emphasized the strategies below for enhancing provider screening:

  1. Utilizing the National Site Visit Contractor (NSVC) to increase the number of site visits to Medicare-enrolled providers and suppliers;
  2. Enhancing address verification software in its Provider Enrollment Chain and Ownership System (PECOS) to better detect vacant or invalid addresses or commercial mail reporting agencies;
  3. Analyzing enrollment data to identify and deactivate provider or supplier numbers meeting specific criteria that have not billed Medicare in the last 13 months; and
  4. Monitoring and identifying potentially invalid addresses on a monthly basis through additional data analysis by checking against the U.S. Postal Service address verification database.

Along with these processes, and as discussed previously on this blog, CMS announced this past February its intent to strengthen provider and supplier enrollment screening – meaning, to scrutinize providers and suppliers even more closely during enrollment.

OIG Recommends Additional Action

In its April report, the OIG noted that in the year after the enhanced screening’s implementation (i.e., March 25, 2012 through March 24, 2013), there were, among other things, fewer enrollment applications and an increase in the rate of returned applications. Also, since the implementation of the risk screening and site visit enhancements, there has been a substantial increase in the volume of revocations and deactivations of existing providers’ billing privileges.

OIG also noted several areas in the implementation of the enhanced screening that needed strengthening. In its report, the OIG recommended the following to CMS (CMS concurred with all recommendations):

  1. Monitor contractors to determine whether they are verifying information on enrollment and revalidation applications as required;
  2. Validate that contractors are appropriately considering site visit results when making enrollment decisions;
  3. Revise and clarify site visit forms so that they can be more easily used by inspectors to determine whether a facility is operational;
  4. Require the NSVC to improve quality assurance oversight and training of site visit inspectors; and
  5. Ensure that CMS’s enrollment data system contains the complete and accurate data needed to execute and evaluate CMS’s enrollment-screening enhancements.

CMS maintains the authority to conduct site visits on all enrolling and enrolled providers to verify that the enrollment information submitted to CMS is accurate, and ensure that Medicare providers are in compliance with the Medicare enrollment requirements.

Provider enrollment in the Medicare program is already a complex process. CMS’s enhanced enrollment screening process makes it even more crucial that providers keep their Medicare enrollment data current and continually monitor facility activities to ensure compliance with CMS’s requirements.