CMS Announces Stepped-Up Provider and Supplier Enrollment Screening

Shantanu Agrawal, M.D., the Deputy Administrator and Director for the Center for Program Integrity at CMS, authored the post affirming that CMS is strongly committed to protecting the integrity of the Medicare program, and intends to use tools provided by the Affordable Care Act to assist in efforts to ensure that only qualified providers and suppliers are enrolled in Medicare. This includes enhanced screening of providers and suppliers on enrollment to identify those potentially at risk for committing fraud. CMS also plans to increase site visits to Medicare-enrolled providers and suppliers; improve information technology systems; and implement data monitoring to assist the agency in making sure practice location data is accurate and consistent with enrollment requirements.

Specifically, Dr. Agrawal stated in the Blog that CMS has implemented the following four strategies to strengthen provider and supplier screening:

1. Increased Site Visits to Providers and Suppliers. CMS has the authority to perform site review of a provider or supplier to verify that enrollment information is accurate and to determine compliance with Medicare enrollment requirements. (See 42 C.F.R. § 424.517.) Under that authority, CMS has increased site visits to providers and suppliers, initially targeting those receiving a high level of Medicare reimbursement that are located in “high risk” geographic areas.

1. Enhanced Address Verification Software. In 2016, CMS is adding Delivery Point Verification (DPV) software to the Provider Enrollment, Chain, and Ownership System (PECOS) to enhance address verification capability. DPV will enable CMS to better identify addresses that may be vacant, invalid, or commercial mail reporting agencies. Verifications will take place during the application process and may trigger additional “ad hoc” site visits.

1. Deactivate Providers/Suppliers Not Billing Medicare for 13 Months. Beginning March 2016, and on a monthly basis thereafter, CMS will analyze enrollment data and deactivate providers or suppliers meeting specific criteria that have not billed Medicare in the previous 13 months. Certain specialty providers and suppliers may be exempted, including those enrolled solely to order, refer, or prescribe. 

1. Comparison with U.S. Postal Service Database to Identify Invalid Addresses. CMS is identifying addresses that may have become non-operational after initial enrollment by validating provider/supplier enrollment practice location addresses against the U.S. Postal Service address verification database. Such analysis is done on a monthly basis.

Providers and suppliers have always had a responsibility to ensure that their enrollment information is accurate when initially submitted and that changes are submitted to CMS on a timely basis. The agency’s increased focus on enrollment, however, may increase the incentive to assure accuracy and to update timely, particularly for those in a “high risk” geographic area and receiving a high level of Medicare reimbursement. Providers and suppliers should also be aware that they may experience an increased number of site visits for verification of Medicare enrollment information.