FACT SHEET
FOR IMMEDIATE RELEASE
February 22, 2016
Contact: CMS Media Relations
(202) 690-6145 | CMS
Media Inquiries
Strengthening
Provider and Supplier Enrollment Screening
The Affordable Care Act (ACA) provided
tools to enhance the Centers for Medicare & Medicaid Services’ (CMS)
ability to screen providers and suppliers upon enrollment and identify those
that may be at risk for committing fraud, including the use of risk-based
screening of providers and suppliers. In addition to implementing the tools
provided by the ACA, CMS is strengthening strategies designed to reinforce
provider screening activities by increasing site visits to Medicare-enrolled
providers and suppliers, enhancing and improving information technology (IT)
systems, and implementing continuous data monitoring practices to help make
sure practice location data is accurate and in compliance with enrollment
requirements.
A recent report by the Government
Accountability Office (GAO) reviewed the implementation of some of CMS’
screening procedures that are used to prevent and deter ineligible or
potentially fraudulent providers and suppliers from enrolling in the Medicare
program. The GAO concluded that, as part of an overall effort to enhance
program integrity and reduce fraud risk, effective enrollment and screening
procedures are essential to make sure that ineligible or potentially fraudulent
providers and suppliers do not enroll in the program and that CMS has taken
steps to develop and implement such procedures. The GAO analysis identified
areas for improvement in our Provider Enrollment Chain and Ownership System
(PECOS) regarding verification of provider and supplier practice locations and
physician licensure statuses. Providers and suppliers are required to supply
the address of the location from which services are offered on their Medicare
enrollment applications.
The GAO’s findings supported CMS’
efforts to further enhance provider and supplier screening activities. CMS has
begun increasing site visits to Medicare-enrolled providers and suppliers,
enhancing and improving IT systems and implementing continuous data monitoring
practices to help make sure practice location data is accurate and in
compliance with enrollment requirements.
Summary
CMS is strongly committed to
protecting the integrity of the Medicare program, including making sure
providers and suppliers enrolled in Medicare are qualified and legitimate. The
Affordable Care Act provided tools to enhance our ability to screen and
identify those providers and suppliers that may be at risk for committing
fraud. In our effort to continuously enhance Medicare program integrity and use
information identified by the GAO, CMS is strengthening strategies designed to
reinforce provider screening activities, specifically:
- Utilizing the National Site Visit Contractor (NSVC) to
increase the number of site visits to Medicare-enrolled providers and
suppliers;
- Enhancing address
verification software in PECOS to better detect vacant or invalid
addresses or commercial mail reporting agencies (CMRA);
- Analyzing enrollment
data to allow us to identify and deactivate providers or suppliers meeting
specific criteria that have not billed Medicare in the last 13 months; and
- Monitoring and identifying
potentially invalid addresses on a monthly basis through additional data
analysis by checking against the U.S. Postal Service address verification
database.
Background
Section 1866(j) of the Social
Security Act (the Act)) requires the Secretary to establish an enrollment
process for Medicare providers and suppliers. Providers and suppliers enrolled
in the Medicare program have specific obligations to, among other things,
notify CMS of any address, licensure or other changes that may impact enrollment
(42 C.F.R. § 424.516). Maintaining accurate addresses of the location from
which providers and suppliers offer services is vital to protecting the
integrity of the enrollment process.
Increasing the Number of Site
Visits
CMS has the authority, when deemed
necessary, to perform onsite review of a provider or supplier to verify that
the enrollment information submitted to CMS or its agents is accurate and to
determine compliance with Medicare enrollment requirements (42 C.F.R. 424.517).
Under this authority, CMS is now increasing site visits, initially targeting
those providers and suppliers receiving high
reimbursements by Medicare that are located in high-risk geographic areas.
CMS believes that increasing site
visits, improving IT systems, and conducting continuous data monitoring will
strengthen the integrity of the Medicare program while minimizing burden on the
provider community. CMS will continue to advise the provider and supplier
community of the importance of maintaining accurate, up-to-date provider
enrollment practice location information. It is important that the provider
community continue to inform CMS of any changes to their enrollment, as
required.
System
Enhancements & Updated Processing Direction
CMS will also replace the current PECOS address
verification software with new software starting in CY2016 that not only
includes the existing functionality but also Delivery Point Verification (DPV).
This new DPV functionality will flag addresses that may be vacant, CMRAs or
invalid addresses. These verifications will take place during the application
submission process and may trigger ad hoc site visits.
Continuous Data Monitoring
On a monthly basis, CMS will run additional
analyses on enrollment data to deactivate providers or suppliers meeting
specific criteria that have not billed Medicare in the last 13 months. CMS may
exclude providers and suppliers from deactivation for non-billing, including:
those enrolled solely to order, refer, and prescribe or certain specialty
types, e.g. pediatricians, dentists and mass immunizers (roster billers). This
approach will remove providers and suppliers with potentially invalid
addresses from PECOS without requiring site
visits.
CMS now continuously monitors and identifies
addresses that may have become vacant or non-operational after initial
enrollment. This monitoring is done through monthly data analysis that
validates provider enrollment practice location addresses against the USPS
address verification database.
CMS BLOG: https://blog.cms.gov/2016/02/22/cms-strengthens-provider-and-supplier-enrollment-screening/
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