Provider revalidation a lone bright spot amid gaps in enrollment screening

Revalidation screening for Medicare enrollment helped weed out a substantial number of ineligible providers, but the Centers for Medicare & Medicaid Services (CMS) still struggles to prevent illegitimate providers from enrolling in Medicare, according to a report from the Office of Inspector General (OIG).

In 2011, Affordable Care Act regulations implemented a host of enhanced enrollment screening initiatives to combat fraud and abuse, including expanding site visits and increasing the frequency of provider revalidation. Although revalidation enhancements triggered a substantial increase in revocations and deactivations, federal investigators were unable to "conclusively" determine whether enhancements prevented ineligible providers from enrolling in Medicare in the first place.

Furthermore, Medicare administrative contractors and the National Supplier Clearinghouse failed to verify key information during the enrollment and revalidation process, including compliance with enrollment standards during site visits.

"That could leave the program vulnerable to approving providers or suppliers that submitted false information," Tanaz Dutia, a team leader with the Office of Evaluations and Inspections at the OIG, said in an accompanying podcast.

The OIG also found that the Provider Enrollment, Chain and Ownership System--the system CMS uses to validate providers and a frequent target of criticism from watchdog agencies--contains incomplete or inaccurate data, and recommended the agency ensure the validity of the database. Among other recommendations, OIG urged CMS to monitor contractor compliance with screening enhancements and improve oversight and inspector training for site visits.

To learn more:
- read the OIG report
- here's the OIG podcast