The Importance of Timely Medicare Revalidation

Revalidation is the process by which the Centers for Medicare & Medicaid Services (CMS) requires a provider to certify the accuracy of its existing enrollment information with Medicare. Revalidation is required every five years, and “off cycle” revalidations (including possible site visits) may also be required. Off cycle revalidations may be triggered by:

  • random checks
  • healthcare 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 the following providers for revalidation:

  • Providers who are not registered in Medicare Provider Enrollment, Chain, and Ownership System (PECOS) to facilitate the entry of the provider’s enrollment information into the system
  • Providers who have not updated their enrollment within the last five years
  • Providers located in historically high-risk areas for fraud
  • Providers who do not receive electronic funds transfer (EFT) payments

Failure to meet Medicare requirements (including revalidation) may mean that the provider’s billing privileges will be deactivated or revoked.

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:

  • a change in ownership or control must be reported within 30 calendar days
  • a change in practice location (within 30 days)
  • a change in billing services (within 90 days)
  • a change in “special payments and correspondence” address (within 90 days)

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

A provider’s billing privileges will remain deactivated until the provider 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 in place at the time of reactivation, and be prepared to submit a valid Medicare claim)

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

Revocation is far more serious, and occurs for failure to comply with Medicare requirements after notification, exclusion from the Medicare program of any owner, felonies, and other conditions set forth in 42 CFR, §424.535.

Revocation has harsh consequences, per CFR §424.535(a)(6)(i):

  • Medicare payments will be halted until the Corrective Action Plan or 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.
  • 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.
  • A provider or organization may be placed on the “List of Excluded Individuals and Entities.”

Preventing Deactivation or Revocation

Medicare requires all changes to your practice be reported within 30 or 90 days of the change to keep your enrollment information current. Make sure to report these changes within the specified time.

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

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  • 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

 

John Verhovshek

John Verhovshek

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.
John Verhovshek

About Has 406 Posts

John Verhovshek, MA, CPC, is Managing Editor at AAPC. He has covered medical coding and billing, healthcare policy, and the business of medicine since 1999. He is an alumnus of York College of Pennsylvania and Clemson University, and a member of the Asheville-Hendersonville AAPC Local Chapter.

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