February 2012 Volume 8 Number 6

Medicare-Enrolled Providers and Suppliers to Revalidate by 2015

By Jeanne L. Vance, Salem & Green, A Professional Corporation, Sacramento, CA

AuthorThe Centers for Medicare & Medicaid Services (“CMS”) has begun the process of revalidating most Medicare provider and supplier enrollments, which must be completed by 2015.1 This effort began making waves in the provider and supplier community when letters sent last fall from the Medicare Administrative Contractors (“MACs”) gave recipients 60 days to respond with a complete Medicare revalidation application. The consequences of failure to comply with a MAC request to revalidate include deactivation2 of a provider or supplier’s enrollment, which means that the Medicare revenue stream ceases.

The revalidation effort is called for under the Patient Protection and Affordable Care Act (“PPACA”), which requires that all providers and suppliers that have enrolled prior to March 25, 2011 revalidate under new program integrity rules that went into effect on that date.3 This means that the vast majority of providers and suppliers are required to revalidate.

Revalidation requirements are nothing new; law in existence prior to the passage of PPACA required all providers and suppliers to revalidate every five years (three years for durable medical equipment, prosthetics, orthotics and supplies (“DMEPOS”) suppliers),4 and also upon request from CMS.5 However, providers and suppliers irregularly received requests to revalidate their enrollment files. Thus, many providers and suppliers will likely be unfamiliar with the revalidation process and the disruptive impact of a possible enrollment deactivation for failure to comply with a MAC request.

For more information on this topic, the Health Law Section is hosting a webinar
Medicare's Revalidation Requirements: Update on Enrollment Procedures for Providers and Suppliers

on March 15, 2012.


What Revalidation Means for Providers and Suppliers

Revalidation requires more than restating a provider or supplier’s Medicare enrollment file anew. This time around, revalidation will require that providers and suppliers be screened under the program integrity rules that went into effect under PPACA.6 Institutional providers can expect a site visit and background check to accompany the revalidation effort.7 In addition, Medicare enrollees who are revalidating will need to provide content for new enrollment forms that were issued in 2011. The most significant changes involve disclosure requirements of those persons and entities that have direct and indirect ownership and control over the Medicare enrollee. The new forms require the exact date ownership or control began, the exact percentage of ownership or control, the date and place of birth of individuals disclosed with an ownership and control interest in the Medicare supplier or provider, and the disclosure of all physician owners of physician-owned hospitals.8 In addition, institutional providers will need to pay a Medicare revalidation enrollment fee (or submit a hardship request) to have the revalidation processed.9

Medicare-enrolled providers and suppliers are under an obligation to report changes to their enrollment records such as location changes, changes to officers and directors, and adverse action occurrences on a timely basis (depending on the type of change and type of provider/supplier, within 30-90 days).10 Thus, providers and suppliers must continue to submit other updates to Medicare and should respond separately even if they have received a revalidation request from the MAC.

Preparing for Revalidation

While CMS has instructed the MACs so far to cooperate with providers and suppliers to ensure compliance (by calling, for example, a provider or supplier who fails to respond to a revalidation request),11 providers and suppliers should seek out with diligence revalidation requests to prevent the disruption of an enrollment deactivation. Medicare enrollees should counsel staff who sort mail at the “special payments” address on file with Medicare where to direct revalidation requests for prompt attention to avoid deactivation of an enrollment based on mere failure to respond to the MAC request. In addition, Medicare providers and suppliers should review the CMS website for a list of providers/suppliers listed by national provider number to see if a revalidation request has been sent (they are sometimes misplaced by the mail courier or misrouted within a provider organization).12

Revalidation requests are issued by national provider identifier; thus, a single organization may have multiple enrollments that must be revalidated. Medicare enrollees should check carefully to determine whether a second or third letter received is a new request or a duplicate. In preparation for on-site visits, providers and suppliers should ensure that the business name is accurate to avoid a finding that the provider or supplier on file with Medicare is not operational at the business location (resulting in a revalidation that is denied, and an enrollment that is revoked). For DMEPOS suppliers, exterior signage is an important condition of payment eligibility.13 In preparation for a site visit linked to revalidation, DMEPOS suppliers who are revalidating should ensure that their posted hours are accurate.

Providers and suppliers who have not yet revalidated will be well-served by advance preparation by gathering the information needed to complete in full the appropriate Medicare enrollment forms. The quick response time required to assemble a full Medicare application after receiving a MAC request will be challenging for most respondents. Diligence on the front-end can help avoid a costly and disruptive enrollment deactivation.


1

CMS, Further Details on the Revalidation of Provider Enrollment Information, MLN
Matters SE1126, Revised August 10 and December 9, 2011,available at https://www.cms.gov/MLNMattersArticles/downloads/SE1126.pdf .; CMS, Important Information on Revalidation of Provider Enrollment, email to ALL-FFS-PROVIDERS@LIST.NIH.GOV list serve, November 4, 2011. 

2 An enrollment revocation with a subsequent term-limited enrollment ban is also possible, but CMS has indicated on several occasions that this enrollment revalidation effort will not result in revocations.
See MLN Matters SE 1126 and Transcript of CMS Revalidation of Medicare Provider
Enrollment National Provider Call, October 27, 2011, available at this link.
3

PPACA, Section 6401(a); see also MLN Matters SE1126.

4

42 C.F.R. 424.515; 42 C.F.R. 424.57.

5

PPACA, Section 6401(a); see also, 42 C.F.R. 424.518.

6

Id.

7

Id.

8

See forms CMS 855A, 855B and 855S issued July 2011, available at http://www.cms.gov/CMSForms/CMSForms/list.asp.

9

42 C.F.R. 424.514.

10

42 C.F.R. 424.516; 42 C.F.R. 410.33(g)(2); 42 C.F.R. 424.57(c)(2).

11

See Transcript of CMS Revalidation of Medicare Provider Enrollment National Provider Call, October 27, 2011, available at this link.

12

http://www.cms.gov/MedicareProviderSupEnroll/11_Revalidations.asp#TopOfPage.

13

42 C.F.R. 424.57(c)(7).


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