Nearly all physicians must revalidate Medicare enrollment by 2013

Doctors are concerned that enrollment problems could lead some in good standing to get kicked out of the program.

By Charles Fiegl — Posted Aug. 29, 2011

Print  |   Email  |   Respond  |   Reprints  |   Like Facebook  |   Share Twitter  |   Tweet Linkedin

Roughly 750,000 physicians in the Medicare program soon will be asked to revalidate their individual enrollment records during a massive anti-fraud effort required by the health system reform law. The Centers for Medicare & Medicaid Services hopes to weed out only the people who shouldn't have billing privileges, but physicians are concerned that legitimate health professionals could get caught up in the enrollment sweep by mistake.

CMS gradually will send revalidation requests by mail to more than 1.4 million health professionals -- more than half of whom are doctors -- between now and March 23, 2013, the agency announced on Aug. 10. Physicians who have enrolled since March 25, 2011, will not be required to revalidate, because their applications were scrutinized under new screening criteria, CMS said. Those receiving a request would have 60 days to recertify their enrollment information, which for some doctors will be similar to the process they first used to sign up with the program.

"Failure to submit the enrollment forms as requested may result in the deactivation of your Medicare billing privileges," CMS stated in the notice.

Previous revalidation efforts have targeted much smaller segments of physicians, such as those who had not updated their enrollment within the past five years or medical suppliers in areas known to be at high risk for fraud. Medicare administrative contractors across the country process about 27,000 new enrollments and more than 30,000 reassignments, or changes to billing and payment information, each month.

Doctors have described Medicare enrollment as tedious and confusing at times. Attempts to strengthen safeguards in the process have created problems for those caring for Medicare patients in recent years. In March, CMS implemented additional program integrity defenses mandated by the health reform law to prevent fraud. Physician practices have reported long wait times for new applications to be approved since then.

"We have very significant concerns with this revalidation effort in light of the problems physicians have had with enrollment and revalidation efforts in the past," said American Medical Association President Peter W. Carmel, MD. "The AMA is making this a priority and urging CMS to reconsider this action."

Physician practice administrators are being told to watch for the letters requesting revalidation, said Allison Brown, a senior advocacy adviser with the Medical Group Management Assn. in Washington. Practices are urged to begin revalidation as soon as they receive a request, she said. Physicians can revalidate using paper applications or by using CMS' online enrollment system, called PECOS, the Provider Enrollment, Chain and Ownership System, which CMS says is the most efficient way to submit necessary information.

But even if every practice complies with the letters as soon as they receive them, the plans to revalidate all health professionals who enrolled before March 25 would require contractors to process thousands of additional applications a day on top of the ones they already receive. Practices also must wait until their Medicare contractor sends them a request before they can revalidate.

"We may end up with enrollment backlogs just given the scope of the revalidation effort," Brown said.

Bureaucratic brick walls

The Neurology Medical Group of Diablo Valley in Pleasant Hill, Calif., saw the hassles of the Medicare enrollment process when it attempted to change the practice address for a neurologist who was starting at the medical group in September 2009.

The initial enrollment application sent in August 2009 went missing. A second application was denied on a technicality, and a third application was approved in February 2010. But the Medicare contractor would backdate the physician's enrollment status only to late November 2009. The contractor has denied the practice $30,000 in Medicare charges billed by the neurologist between September and November of 2009.

"It was insufferably delayed, so we could not serve Medicare patients," said Steven Holtz, MD, a neurologist at the group.

The practice recently hired another neurologist, who will start on Sept. 1. The practice sent the physician's Medicare enrollment application in July, but the contractor returned the application and noted that it was sent too early, said Nadia George, the practice administrator. Resending it on Aug. 1 resulted in an approval two weeks later, but that was short-lived. "The next day I received an email that said [the application] was rejected," she said.

She followed up with a phone call to the contractor's enrollment department and was told the application appeared to be approved. George is planning to have the new hire treat one Medicare patient before Sept. 1 and have him submit a claim to ensure that the physician is in the Medicare system.

Such an experience is not unique. Physicians tend to find enrolling in the Medicare program an unnecessarily long, complicated and bureaucratic process, said Donald Waters, executive director of the Alameda-Contra Costa (Calif.) Medical Assn. It's a task often left to professional credentialing staff and practice administrators. But even the most experienced staffers encounter problems with confusing language on enrollment forms and vague instructions that cost physician practices time and money, Waters said.

The MGMA's Brown said CMS has planned improvements to the enrollment website. Changes would allow physicians to sign online applications electronically, instead of having to print a certification statement for the application and mail it to a contractor. The improvements could be implemented by January 2012, she said.

Back to top


A massive re-enrollment effort

View in PDF

Click to see data in PDF.

Medicare plans to revalidate the enrollments of more than 1.4 million individuals and facilities by March 23, 2013. Physicians account for more than half the list.

Health professional type Enrollments % of total
Physicians 750,836 52%
Nonphysicians 300,362 21%
Clinics, group practices and others 241,441 17%
Equipment suppliers 102,104 7%
Institutional professionals 49,926 3%
Total (as of March 2) 1,444,669 100%

Source: "Provider Screening Statement of Work," Centers for Medicare & Medicaid Services, draft, May 27 (link)

Back to top

Doctors considered low risk

Health professionals are subject to different screening criteria during the Medicare enrollment process. Physicians and nonphysician practitioners fall in the limited-risk category; physical therapy, x-ray suppliers and currently enrolled home health agencies are in the moderate risk category; and new home health agencies and new equipment suppliers are in the high-risk category.

Type of screening Limited Moderate High
Verification requirements set by Medicare Yes Yes Yes
License verifications Yes Yes Yes
Verification of Social Security numbers, taxpayer ID numbers, etc. Yes Yes Yes
Unscheduled site visits No Yes Yes
Fingerprint-based background checks No No Yes

Source: "Provider Screening Statement of Work," Centers for Medicare & Medicaid Services, draft, May 27 (link)

Back to top



Read story

Confronting bias against obese patients

Medical educators are starting to raise awareness about how weight-related stigma can impair patient-physician communication and the treatment of obesity. Read story

Read story


American Medical News is ceasing publication after 55 years of serving physicians by keeping them informed of their rapidly changing profession. Read story

Read story

Policing medical practice employees after work

Doctors can try to regulate staff actions outside the office, but they must watch what they try to stamp out and how they do it. Read story

Read story

Diabetes prevention: Set on a course for lifestyle change

The YMCA's evidence-based program is helping prediabetic patients eat right, get active and lose weight. Read story

Read story

Medicaid's muddled preventive care picture

The health system reform law promises no-cost coverage of a lengthy list of screenings and other prevention services, but some beneficiaries still might miss out. Read story

Read story

How to get tax breaks for your medical practice

Federal, state and local governments offer doctors incentives because practices are recognized as economic engines. But physicians must know how and where to find them. Read story

Read story

Advance pay ACOs: A down payment on Medicare's future

Accountable care organizations that pay doctors up-front bring practice improvements, but it's unclear yet if program actuaries will see a return on investment. Read story

Read story

Physician liability: Your team, your legal risk

When health care team members drop the ball, it's often doctors who end up in court. How can physicians improve such care and avoid risks? Read story

  • Stay informed
  • Twitter
  • Facebook
  • RSS
  • LinkedIn