On July 21, 2015, the Government Accountability Office (GAO) released a report titled “Additional Actions Needed to Improve Eligibility Verification of Providers and Suppliers” examining the implementation of four of CMS’s enrollment screening procedures used to detect ineligible or potentially fraudulent providers and suppliers and prevent them from enrolling into CMS’s Provider Enrollment, Chain and Ownership System (PECOS).  The GAO identified weaknesses in two of the four enrollment screening controls examined—practice location and physician licensure verifications. 

The GAO’s examination of 2013 data found that approximately 22 percent of practice location addresses are potentially ineligible.  The GAO also found that the current system for physician licensure verifications, which relies on physicians to self-report final adverse actions and focuses on the license numbers used in enrollment applications, contains vulnerabilities.

In a response letter, CMS stated that it plans to incorporate flags into its software to help identify potentially questionable addresses, take steps to make certain that applicant licensure information is evaluated by contractors, and regularly review databases for disciplinary actions against enrolled providers and suppliers.

While the GAO report targets CMS and its contractors’ screening efforts, providers may also wish to consider the following:

  • The GAO report demonstrates the continued emphasis on prepayment enforcement controls.  Providers may notice a “trickle down” effect as CMS’s ability to keep problematic providers out of the system becomes increasingly scrutinized.
  • The GAO’s critique of physician enrollment controls that rely on self-reported information may foreshadow a future trend.  As screening efforts continue to evolve, increasing emphasis may be placed on the screening party’s own efforts versus reliance on representations made by the screened party.

Accordingly, providers may wish to review their screening processes and consider enhancements. 

The GAO report is available here. The GAO Report was also presented at a Senate Committee on Aging hearing on July 22, 2015. Hearing information and testimony is available here.  The statement of Seto J. Bagdoyan, Director, Forensic Audits and Investigative Service, is available here.