Medicare Revalidations Continue, Along with a Few Issues

Regular Medicare revalidations, which were mandated in the Affordable Care Act and commenced in March 2016 after the Centers for Medicare and Medicaid Services (CMS) completed their first widespread validation of all Medicare providers, are in full-swing. But the process is not without its challenges.

Revalidations are part of CMS’s provider screening process and are intended to help reduce fraud and abuse. DME suppliers are required to revalidate every 3 years, and all other providers and suppliers must revalidate every 5 years.

How It Works

Here’s how the system is supposed to work:

All revalidation due dates are the last day of the month, and providers can submit their revalidations up to six months prior to their due date. Assigned due dates for round two revalidations will generally stay the same for subsequent revalidations and are established based on the provider’s initial enrollment (for newly enrolled providers) or the last successful revalidation.
Providers will be notified of their assigned revalidation deadline by their Medicare Administrative Contractors (MACs) within 2-3 months prior to the revalidation due dates. Notifications are sent by email (if email addresses have been reported on prior applications) or by regular mail for those who do not have an email address on file or if the email was returned as undeliverable.
CMS also publishes a list of Medicare providers and suppliers and their assigned due dates on the Medicare Revalidation website. As due dates are assigned, they are added to the list, and until a deadline is assigned, the provider’s “Revalidation Due Date” column will show TBD.
To submit a revalidation application, providers can use CMS’s Internet-based PECOS or complete the appropriate CMS-855 application. In both cases, providers should also submit all supporting documentation before the due date as well. Institutional providers of medical or other items or services and suppliers are required to submit an application fee of $554 for revalidations. However, this fee does not apply to physician and non-physician practitioner organizations.

The Problems

Problems arise, however, when providers do not receive those important notifications of their assigned revalidation due dates. According to Denise O’Brien, CIPROMS Director of Provider Enrollment, some providers report that they have not received notifications by any means. Also, O’Brien has been told that notifications are being mailed only to the primary practice, or physical, address on file for a provider, even though CMS claims on their website to send letters to at least two of the three addresses they maintain on file: correspondence, special payments, and/or primary practice addresses. For hospital-based providers like anesthesiologists and emergency physicians, that means the letters are being sent to the hospital and never actually find their way to the physician.

O’Brien, who also serves at the co-chair of the Emergency Department Practice Management Association’s (EDPMA) provider enrollment committee, is working with EDPMA to petition CMS to require MACs to send revalidation notice letters to all three addresses on file to give providers a better chance of receiving the information.

Receiving notification is crucial because providers are not allowed to revalidate until they are assigned a due date. However, once a due date has been assigned, the revalidation will be due even if the provider does not receive an emailed or mailed notification. In fact, CMS recommends that providers who are within two months of the listed due date on the revalidation list should go ahead and submit their revalidation application even if they have not received a notice from their MAC.

That means it is up to providers to periodically review the Medicare Revalidation list to see if a due date has been added. That list does offer easy to use search features to look up individual providers or groups. However, keeping track of many providers in a group (or in many different groups as is the case with a billing company) becomes difficult because the list contains all providers in the Medicare program and is so large it becomes unwieldy to download and query. Also, because the list is updated every 60 days when new due dates are established, providers have to repeatedly check the list to see if their revalidation due date has been assigned.

The biggest problem with the list, however, are inaccuracies. According to O’Brien, provider due dates are not reverting back to TBD after the revalidation is complete, as CMS has indicated they would. Also, some recently enrolled or recently revalidated providers are showing up on the list with new (and thus incorrect) revalidation due dates, and some providers are listed with old or no longer valid PTANs. All of these inaccuracies mean more work for providers and their staff or billing company.

But the process is more than just an aggravation. The consequences for not revalidating can be devastating, including a possible hold on providers’ Medicare payments or even deactivation of Medicare billing privileges. Deactivated providers will be required to submit a new complete application to reactivate their enrollment, and the reactivation date will be the date the new application is completed, which means no payments will be made for the period of deactivation.

What You Should Do

In order to avoid having Medicare payments held or Medicare billing privileges revoked for your practice, follow these steps:

Be on the lookout for an email or letter indicating your revalidation due date has been assigned. NOTE: The mailed notifications no longer arrive in the bright yellow envelopes we all grew accustomed to in the initial revalidation cycle.
Create a reminder for yourself to review the Medicare Revalidation List every 60 days to see if your revalidation due date has been added.
As soon as you receive a letter or discover your date on the list, go ahead and revalidate your Medicare enrollment.
Check the status of your revalidation to ensure all information and documentation has been received.
Since revalidations are due every five years for most providers, once you revalidate, make a note for yourself or your staff to begin checking the Medicare Revalidation List again in four years for a new due date. Also, keep a record of past revalidations in case a new revalidation due date is incorrectly assigned to you before you are actually required to revalidate again.

For more information, review CMS’s Revalidations webpage or the Revalidation FAQs.