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Medicare Providers to Revalidate

In a massive anti-fraud effort, approximately 750,000 physicians in the Medicare program will be asked to revalidate their individual enrollment records by next year. The revalidation is required by the health system reform law to target fraud, waste, abuse and improper payments made each year. In 2010, the Medicare agency estimated $48 billion in improper payments. “Medicare crooks are robbing the American taxpayer each and every year of the same amount it took Bernie Madoff decades to rob from his private investors,” said cardiothoracic surgeon Dr. Boustany.

From now through March of 2015, the Centers for Medicare and Medicaid Services (CMS) will mail out revalidation requests to over 1.4 million individuals and facilities, more than half of whom are doctors. Physicians who have enrolled on or after March 25, 2011, will not be required to revalidate, as their applications were already scrutinized under new screening criteria. Those receiving a request would have 60 days to recertify their enrollment information. Failure to submit the enrollment forms as requested may result in the deactivation of Medicare billing privileges. Though it’s known that the enrollment process can be long, confusing and tedious, CMS is continuing to fix its bugs on the Internet based PECOS (Provider Enrollment, Chain and Ownership System), intended to be used in lieu of the paper based Medicare enrollment application.

Healthcare professionals and facilities are subject to different screening criteria based on their risk level during this Medicare enrollment process. Screenings include unscheduled site visits, license verifications, verifications set by Medicare, background checks, fingerprinting, and more. Physicians and non-physician practitioners fall in the low-risk category, whereas new equipment suppliers and new home health vendors are considered to be much higher on the risk scale. Physical therapy, x-ray suppliers and currently enrolled home health agencies are in the moderate risk category.

Medicare’s Action Against Future Fraud

The fiscal 2012 budget proposal estimates that health care program integrity efforts will save $32.3 billion over the next decade. The new anti-fraud tools designed to help achieve this goal include:

  • Enhanced screening and enrollment protections that require high-risk health care professionals to face greater scrutiny when signing up.
  • The ability for CMS to discontinue payment of suspect claims immediately when a credible allegation of fraud arises.
  • More funding to investigate fraud and for other program integrity resources.
  • Expanded use of recovery audit contractors in Medicare Advantage, Medicare part D and Medicaid.
  • Data analytics and increased data-sharing among federal agencies that will allow the government to analyze claims for deviant activity in real time.

While new technology and tools are being designed to help prevent fraud, the importance of education and creating physician awareness about fraudulent activities, such as identity theft, is also critical.

If you have questions or need more information regarding Medicare’s revalidation process, don’t hesitate to contact us at Amber.

Posted by:
Bobby Serros
President / CEO

Useful links & References:

CMS Revalidations

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