Experience. Integrity. Advocacy.
Experience. Integrity. Advocacy.

CMS Strengthens Provider and Supplier Enrollment Screening


Using several new strategies, including tools provided by the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) is strengthening its screening process for providers and suppliers enrolling in the Medicare program.

A report by the Government Accountability Office (GAO) recently highlighted the need for improved screening to “prevent and deter ineligible or potentially fraudulent providers and suppliers from enrolling in the Medicare program.” As well, the GAO identified aspects of the Provider Enrollment Chain and Ownership System (PECOS) that should be enhanced in order to verify provider and supplier practice locations and physician licensure statuses.

In a recent post on the CMS blog, Shantanu Agrawal, M.D., CMS Deputy Administrator and Director, Center for Program Integrity, outlined the key strategies CMS will implement, including the following:

  • Increase the number of site visits to Medicare-enrolled providers and suppliers.CMS has increased site visits, initially targeting those providers and suppliers receiving high reimbursements by Medicare that are located in high risk geographic areas.
  • Enhance address verification software in PECOS to better detect vacant or invalid addresses or commercial mail reporting agencies (CMRAs). Starting this year, CMS will replace the current PECOS address verification software with new software that includes Delivery Point Verification (DPV) in addition to the existing functionality. These verifications will take place during the application submission process and may trigger additional ad hoc site visits.
  • Deactivate providers and suppliers that have not billed Medicare in the last 13 months. Beginning March 2016 and on a monthly basis, CMS will run analysis on enrollment data to deactivate providers or suppliers meeting specific criteria that have not billed Medicare in the last 13 months.
  • Monitor and identify potentially invalid addresses on a monthly basis through additional data analysis by checking against the U.S. Postal Service address verification database. This monitoring is done through monthly data analysis that validates provider and supplier enrollment practice location addresses against the U.S. Postal Service address verification database.

“CMS is strongly committed to protecting the integrity of the Medicare program, including making sure only qualified providers and suppliers are enrolled in Medicare,” Agrawal said.

What Should You Do?

The main thing providers can do is keep their enrollment information up-to-date via the PECOS system or using paper forms. “If you are a provider or supplier, you can help us protect the integrity of the Medicare program by informing us promptly of any changes to your enrollment, as required,” Agrawal said.

Up-to-date enrollment information means even if you are flagged for screening, your enrollment will not be affected.

For more information about the new screening processes, review the CMS Special Enrollment Confirmation Process Fact Sheet.

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Charity Singleton Craig

Charity Singleton Craig is a freelance writer and editor who provides communications and marketing services for CIPROMS. She is responsible for creating, editing, and managing all content, design, and interaction on the company website and social media channels in order to promote CIPROMS as a thought leader in healthcare billing and management.

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