Timely Medicare Revalidation May Prevent Deactivation or Revocation

Act now to keep your billing privileges and avoid disruption of reimbursement.

By Delly E. Parham, AS, CPC

Revalidation is the process by which the Centers for Medicare & Medicaid Services (CMS) requires a provider to certify her accuracy or her existing enrollment information with Medicare. Complying with revalidation requests within the specified time is necessary to avoid loss of billing privileges and disruption of Medicare reimbursements.

Revalidate when Requested

Medicare requires revalidation every five years, but also may perform “off cycle” revalidations (including possible site visits). Off cycle revalidations may be triggered by:

  • Random checks
  • Health care fraud problems
  • National initiatives
  • Complaints, or other reasons that cause CMS to question the provider’s/supplier’s compliance with Medicare enrollment requirements
  • CMS is actively targeting for revalidation:
  • Providers who are not registered in the Medicare Provider Enrollment, Chain, and Ownership System (PECOS)
  • Providers who have not updated their enrollment within the last five years
  • Providers located in historically high-risk areas for Medicare fraud
  • Providers who do not receive electronic funds transfer (EFT) payments

Note: Do not submit a revalidation application unless a Medicare contractor contacts you. Upon receipt of the notification, you must respond within 60 days of the request (see 42 Code of Federal Regulations (CFR), chapter IV, §424.515).

Certain Changes Require Revalidation

Certain enrollment information changes, such as a change in practice location or a change in the “special payments and correspondence” address on file with Medicare, may affect timely compliance with revalidation requests. Medicare sends its revalidation letters and other correspondence to the “special payment and correspondence address” on file with Medicare. If a correspondence is returned to Medicare marked “undeliverable,” or if a provider does not respond to Medicare’s request within the time specified in the notice, the provider’s billing privileges will be deactivated or revoked.

Deactivation vs. Revocation

Deactivation of a provider’s Medicare billing privileges is distinct from revocation of Medicare enrollment and billing privileges.

Deactivation is minor. Medicare may deactivate a provider’s Medicare billing privileges if the provider does not report a change to the information supplied on the enrollment application within a specified time.

Significant changes include, but are not limited to:

  • Ownership or control (report within 30 days)
  • Practice location (report within 30 days)
  • Billing services (report within 90 days)
  • “Special payments and correspondence” address (report within 90 days)

You can find a complete list of reportable changes (view “Q12”). Additional information can be found in CFR, §424.520(b) and §424.550(b) (search online to find “Code of Federal Regulations, Section 424”).

A provider’s billing privileges will remain deactivated until he or she either:

  • submits a new enrollment application (CMS 855); or
  • when deemed appropriate, at a minimum, recertifies that the enrollment information currently on file with Medicare is correct. (The provider or supplier must meet all current Medicare requirements at the time of reactivation, and be prepared to submit a valid Medicare claim. Best practice is to contact your Medicare carrier for guidance.)

Claims for services from the date of deactivation to the date of reactivation may not be payable.

Revocation is far more serious. Revocation occurs for noncompliance, misconduct, felonies, falsifying information, and other such conditions set forth in 42 CFR, §424.535.

Revocation has devastating consequences for providers. According to CFR §424.535(a)(6)(i):

  • Medicare payments will be halted until the corrective action plan or request for reconsideration process is complete.
  • The provider is barred from participating in the Medicare program from the effective date of the revocation until the end of the re-enrollment bar. What’s worse, a provider may not receive the notice until months later, unaware that he or she will be forced to forfeit income earned between the time the letter was mailed and when it was received.
  • Any provider agreement in effect at the time of revocation is terminated effective with the date of revocation.
  • The re-enrollment bar is a minimum of one year, but not greater than three years, depending on the severity of the basis for revocation. (The re-enrollment bar may be waived if a provider is revoked based on failure to submit an application fee, or a hardship exception is requested with an enrollment application upon revalidation.)
  • A provider or organization may be placed on the “List of Excluded Individuals and Entities.” (This will affect contracting with other government programs.)

Challenging Revocation

After receiving a revocation letter, a provider has 30 days to submit a corrective action plan and 60 days to submit a request for reconsideration. Providers should submit both documents at the same time because the 60-day time frame for a request for reconsideration starts the day the revocation letter is dated.

A corrective action plan includes:

  • a signed letter explaining why revocation occurred, and what efforts will be used to meet compliance;
  • a signed statement by the provider swearing to the accuracy of the supplied information; and
  • a new CMS Form 855.

If a corrective action plan is accepted, the revocation is rescinded and the provider’s billing rights are restored as of either the date the provider became compliant or the revocation’s original effective date. There is no appeal for a denied corrective action plan.

A reconsideration request may be done in some situations, such as when a provider changed location or Medicare did not update the provider’s address change in its system. A request for reconsideration contends that revocation was erroneous.

Prevent or Minimize Deactivation or Revocation

Medicare requires all changes to your practice be reported within 30 or 90 days to keep your enrollment information current. Make sure to report these changes (see www.cms.gov/MedicarePro​viderSupEnroll/downloads/GettingStarted.pdf) within the specified time.

To complete a revalidation application or to report a change, the provider/supplier may use either the Internet-based PECOS or a traditional paper application. Regardless of which method is used, the provider must complete the following:

The applicable CMS-855 Enrollment Application form:

  • 855B: Medicare Enrollment Application for Clinics, Group Practices, and Certain Other Suppliers;
  • 855I: Medicare Enrollment Application for Physicians and Non-Physician Practitioners
  • 855S: Medicare Enrollment Application for Durable Medical Equipment, Prosthetics; Orthotics, and Supplies (DMEPOS) Suppliers
  • CMS-588 Electronic Funds Transfer Authorization Agreement form
  • Certification and other supporting documentation requested by Medicare, such as a copy of IRS CP-575

These forms may be found at: www.cms.hhs.gov/MedicareProviderSupEnroll/.

CMS says that 90 percent of applications and changes of information submitted through PECOS are processed within 45 days of receipt of the signed and dated Certification Statement, versus 80 percent during the same time for paper applications (depending on the changes made to the application, processing can take over six months). To use PECOS, you must have your organization or individual National Provider Identifier (NPI).

If you use PECOS to make any changes, complete enrollment revalidation, or report a change, and find that you need assistance with your user ID or password, you may contact the help desk.

Verify Enrollment

Providers should verify their enrollment, or pending enrollment, in PECOS. To do this you will need to set up access to PECOS. For information on how to do this, go to the CMS website.

If you do not have an enrollment record, you should submit your enrollment application. Call your local carrier if you have questions or need instruction. For a direct toll-free number, go to the CMS website.

Find more tips on how to enroll in PECOS on the CMS website.

Delly E. Parham, AS, CPC, is a billing/managed-care consultant. For 12 years, she worked in billing and coding and oversaw a billing department. She is the president of AAPC’s Sarasota/Manatee, Fla. local chapter. She helped to rewrite the Complete Coder for Dermatology for the dermatology practice, Inga Ellzey Practice Group, and writes billing articles for AAPC’s Billing Insider. Delly also assists in coordinating activities for Sunday school students.

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