Medicare revalidations, a horror story in the making

While Halloween only comes around once a year, hospitals are constantly faced with truly horrifying provider enrollment and credentialing issues. When not managed correctly, the financial impact can be bone chilling. In honor of Halloween, Newport Credentialing Solutions’ Vice President of Operations, Allyson Schiff, kicks off this holiday series by discussing one of the most grotesque provider enrollment issues facing hospitals today, menacing Medicare revalidations. Continue reading if you dare.

CMS’ nation-wide revalidation initiative requires all qualified, Medicare-enrolled providers to resubmit and recertify the accuracy of their enrollment information every five years. Medicare sends these notifications via paper mailto three mailing addresses: correspondence, remittance, and special payment addresses. While all of this seems pretty straightforward, it is at this point where the nightmare often begins.

Medicare only sends revalidation notices to the locations they have on file.If a provider joined a group but was previously participating in other groups, chances are the letters will not make it to the provider’s current address. Therefore, like a ghost, the letters may never be seen. Without knowing a revalidation is due, the deadline will likely be missed, the provider deactivated from Medicare, and a freeze placed on the physician’s account. How’s THAT for frightening!

Wait, there’s more. If the provider did notreceive the revalidation letter,it is highly unlikely they will receive the dreadful “Do Not Forward”(DNF)letter that states their Medicare reassignment has been stopped. If the provider did not respond to the DNF letter within the 120-day deadline, the provider is terminated from Medicare with no possibility of their account being reinstated. Even more frightening, the provider is unaware of the termination until they are no longer receiving Medicare payments.

If this gruesome error occurs after the 120 days, the provider is forced to get a new PIN number for Medicare AND a new effective date of service.All of this means the providerwill not receive payment for the time in-between the date the DNF was issued and the new date of service.However, if the error is correctedwithin the 120 days, and everything submitted as required, the provider may be re-awardedtheir PIN, provider transaction access number, and the original effective date.

Unfortunately, this grisly situation is one that plays out all too often. However, there are some simple steps hospitals can take to avoid becoming the next victim of Medicare revalidations.

Revalidation options

Medicare has established an online running list of providers that are either due for revalidation, on a DNF profile, or no longer listed with Medicare. However, because this site is not updated frequently, it is not safe for a provider to assume they are not up for revalidation simply because their name is not on the list. Calling Medicare directly is the quickest way to validate a provider activation and revalidation status. Though this process works fine for a small practice, itis a wicked undertaking for large academic medical centers and hospitals with literally hundreds of providers.

Medicare’s PECOS initiative, which replaces paper applications with online applications, is another option that is growing in popularity. Using their NPI user name and password, providers can log into the PECOS site and see a brief snapshot of their enrollment status. While PECOS is much more convenient and more accurate than viewing the online list or phoning Medicare, relying onproviders to take the time and log into PECOS is not always realistic. Furthermore, the revalidation process itself can be downright evil, particularly for seasoned providers. Medicare requires information on every place the provider has worked throughout their career. Applications will not be processed unless the provider supplied all requested information precisely.

Minimizing the pain

Medicare revalidations are a never ending nightmare providers are forced to relive every five years. Relying on theproviders to monitor and manage this dreaded process can be an unnerving and often costly decision. For hospitals that don’t have the right processes in place to manage this grisly endeavor, lost revenue is inevitable.

To avoid becoming the next Medicare revalidation victim, more and more hospitals are opting to outsource the provider enrollment process. Partnering with a credentialing and provider enrollment company that is familiar with the process requirements and has the technology in place to continuously monitor and manage provider enrollment status can truly be a life (and money) saver. However, be forewarned, not all provider enrollment companies are equal. Ensure they have experience, proven track record and technology to ensure a successful program. Otherwise, there will be no escaping the curse of Medicare revalidations!

Stay tuned for the next article in this Halloween series which will discuss the dreaded physician privileging process.

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