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Medicare Revalidation: What Do Health Care Providers Need to Know?

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All Medicare-participating health care providers and medical businesses are subject to revalidation. The revalidation process involves confirming the accuracy of the provider’s enrollment data (or making updates, if necessary), and it must be completed upon request from the Centers for Medicare and Medicaid Services (CMS). According to CMS:

“Medicare providers must revalidate their enrollment record information every three or five years. CMS sets every provider’s revalidation due-date at the end of a month, and posts the upcoming six to seven months online. A due date of ‘TBD’ means that CMS has not set the date yet.”

While Medicare revalidation should be a fairly straightforward process, mistakes made prior to and during revalidation can result in loss of Medicare eligibility and other penalties. As a result, Medicare-participating health care providers must take the revalidation process seriously; and, if they have previously failed to notify CMS of changes in their enrollment data, they must address these failures cautiously in order to avoid costly penalties.

10 Key Facts about the Medicare Revalidation Process

1. Most Medicare Revalidation Requests are Based on Systematic Scheduling.

Typically, the fact that a health care practice or medical business is being asked to revalidate does not in itself suggest an implication of impropriety. Most revalidation requests are a matter of routine, and they are triggered by CMS’s systematic scheduling rather than specific concerns regarding the accuracy of a particular provider’s enrollment data. As noted above, CMS typically requires Medicare-participating practices and businesses to revalidate every three to five years, with durable medical equipment (DME) companies typically facing revalidation every three years, and providers and other suppliers typically being asked to revalidate every five years.

2. Some Revalidation Requests are Based on Complaints and Other Red Flags.

However, while most revalidation requests are the result of systematic scheduling, some are not. If you receive a request for an “off-cycle” revalidation (i.e. if you receive a revalidation request less than three or five years after your most-recent prior revalidation), this may reflect a specific concern with regard to your practice’s or business’s enrollment data. To avoid issues, it will be important to determine why you have received an off-cycle revalidation request and to address any problems with your Medicare enrollment data as soon as possible.

3. The Revalidation Process is Administered by CMS’s Medicare Administrative Contractors (MACs).

When going through the process of revalidating your Medicare enrollment data, you will need to deal with your assigned Medicare Administrative Contractor (MAC). MACs are private entities engaged to conduct audits and revalidations as part of CMS’s “fee-for-service” Medicare administration and auditing program.

4. There are No Exceptions to the Requirement to Revalidate with CMS.

All Medicare-participating health care providers and businesses are required to revalidate every three to five years (and to complete off-cycle revalidations as requested). If you do not believe that you have received a revalidation request within the past three or five years (depending on the nature of your business or practice), then it may be in your interests to inquire with CMS or the MAC assigned to your geographic area. The easiest way to check is by entering your practice or business information into CMS’s Medicare Revalidation List; however, if you have concerns, you may not want to rely on this list exclusively.

5. It is Not Possible to Request an Extension for Submitting Medicare Revalidation Data.

Although MACs previously accepted extension requests from providers and other businesses who were delayed in submitting their Medicare revalidation data, this is no longer the case. According to CMS:

“MACs will no longer process and allow for extension requests from the providers/suppliers who need more time to complete their revalidation. The posted due dates and the revalidation notices issued in advance by the MACs should provide the provider/supplier sufficient notice and time for submit their revalidation application into the MAC prior to their due date.”

In addition to completing the appropriate sections of the CMS 855 application form, providers and businesses must also submit:

  • All National Provider Identifiers (NPIs);
  • Relevant Internal Revenue Service (IRS) documentation (including legal business name and employer identification number (EIN));
  • Copies of board certifications (if applicable);
  • Copies of business licenses and certifications (if applicable); and,
  • CMS-588 Electronic Funds Transfer (EFT) form (if applicable).

For a complete list of revalidation requirements, you can download CMS’s Revalidation Application Checklist.

6. You May Need to Submit Additional Information in Order to Revalidate.

While Medicare revalidation is often a one-step process, this is not always the case. If the MAC reviewing your application believes that you have omitted any necessary information, it may ask you to supplement the information you have provided. If this happens, you must submit the requested information within 30 days in order to avoid temporary suspension of your practice’s or business’s Medicare billing privileges.

7. You May Also Be Required to Submit to an On-Site Inspection.

In some cases, CMS also requires health care providers and medical businesses to submit to on-site inspections as part of the revalidation process. The purpose of these on-site inspections is to confirm the accuracy of providers’ and businesses’ Medicare enrollment data. If, based on the results of an on-site inspection, CMS determines that a provider has failed to satisfy the enrollment criteria or is unable to meet the conditions for revalidation going forward, then it can suspend – and potentially revoke – the entity’s Medicare enrollment.

8. Revalidation is Not Guaranteed.

As the foregoing discussion suggests, revalidation is not guaranteed. Although revalidation is usually a fairly straightforward process, issues can lead to suspension or revocation of Medicare eligibility. From failing to timely submit a revalidation application to failing to meet the criteria for Medicare enrollment, there are various issues that can result in the temporary or permanent cessation of Medicare billing privileges.

9. The Consequences of Failing to Timely Revalidate Can Be Substantial.

Depending on the specific circumstances and the issue (or issues) involved, the consequences of failing to timely revalidate Medicare enrollment data can be substantial. The consequences of failing to revalidate can include:

  • Deactivation of Medicare billing privileges;
  • Temporary suspension of Medicare enrollment;
  • Permanent revocation of Medicare enrollment; and/or,
  • Suspension of payment on pending Medicare billings.

Typically, a suspension on Medicare enrollment will last for a period of one year, and payment of pending Medicare claims may be suspended during this period (CMS refers to this as a “hold”). Revocations can last for up to three years; and, for certain Medicare enrollment violations, health care providers and medical businesses can lose their Medicare eligibility permanently. If your enrollment is deactivated due to a failure to revalidate, you will be required to submit an original enrollment application in order to reactivate, and you will be prohibited from billing Medicare during the period of deactivation.

10. Issues Uncovered During the Revalidation Process Can Trigger Medicare Audits and Investigations.

If issues uncovered during the revalidation process appear to be indicative of intentional or unintentional Medicare fraud, they can also trigger an audit or investigation by the MAC, CMS, or another Medicare audit contractor or federal agency. Depending on the nature and severity of the issues involved, an audit or investigation can potentially lead to substantial civil or criminal penalties. In addition to permanent loss of Medicare eligibility, these penalties can include:

  • Recoupments;
  • Treble (triple) damages;
  • Civil monetary penalties (CMP) or criminal fines;
  • Attorneys’ fees and costs; and,
  • Federal imprisonment.

Avoiding Mistakes and Penalties During the Medicare Revalidation Process

Due to the potential for severe consequences and the complexity of the Medicare billing regulations, health care providers, DME companies, and other medical businesses are advised to seek legal representation during the revalidation process. At Oberheiden, P.C., our attorneys have extensive experience in all Medicare-related compliance and enforcement matters, including enrollments, revalidations, audits, investigations, grand jury proceedings, trials, and appeals. We have represented clients in matters involving MACs, CMS, and other auditors and agencies across the country, and several of our attorneys previously prosecuted Medicare fraud cases on behalf of the federal government.

Due to the routine nature of the Medicare revalidation process, practitioners, company executives, and others are often lulled into a false sense of security. Our attorneys can help you avoid costly assumptions, and we can protect you against the consequences of mistakes such as failing to update your Medicare enrollment data with CMS. If your business or practice is at risk of being targeted in an audit or investigation, we can deal with the relevant auditor or federal authority on your behalf, and we can seek to resolve the matter favorably without publicity and without civil or criminal charges being filed.

Speak with a Medicare Compliance and Defense Lawyer at Oberheiden, P.C.

If your health care practice or medical business is up for revalidation, we encourage you to contact us to learn more about what we can do to help. To schedule a free and confidential consultation with a Medicare compliance and defense lawyer at Oberheiden, P.C., please call 888-519-4897 or inquire online today.

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