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As with other initiatives from CMS, the true volume and scope of this overall revalidation process has become evident. The increased workload for the Medicare administrative contractors (MACs) has been duly noted.


Some suppliers, particularly physicians, have already received letters requesting the revalidation of their enrollment with the Medicare program.  Needless to say, there have been some significant challenges in that the letters do not always get to the intended destination in time. This means that enrollment can be suspended or revoked without the knowledge of the physician.


While physicians are currently the main focus, hospitals, nursing facilities, home health agencies, ambulatory surgery centers, and other providers and suppliers will certainly be addressed in the near future.  If for any reason you think that you should have received a request for revalidation, be certain to contact your MAC to check on your status.  This is simply a safeguard, just in case!


The Challenges


So what is the big deal?  One challenge is that there are now six CMS-855 forms:



  • CMS-855-A – Hospitals and Institutional Providers (Part A)
  • CMS-855-B – Clinics (Part B)
  • CMS-855-I – Individual Physicians and Practitioners
  • CMS-855-O – Ordering or Referring Physicians/Practitioners
  • CMS-855-R – Reassignment
  • CMS-855-S – Durable Medical Equipment



Several of these forms are long and fairly complex. The newest CMS-855 is the form for ordering or referring physicians. CMS has long wanted to implement its requirement that claims contain identification for the ordering or referring physician or practitioner.


What CMS did not realize is that there are many physicians who have never enrolled in the Medicare program because they do not ordinarily bill the Medicare program. Thus, the requirement for identifying ordering or referring physicians cannot be implemented until all of them are enrolled in the Medicare program, which is no small task.


Note that on July 1, 2011, CMS released the latest revision to the different CMS-855 forms-a release that the agency did not even announce!  The forms just appeared on the CMS website. Of course, there were changes in the forms including some new information.


For instance, the CMS-855-A now includes a reporting requirement that the exact percentage of management responsibility must be listed. What this requirement really means is not completely clear. CMS has indicated that this data does not currently need to be reported. Note that the exact percentage breakdown of ownership also does need to be reported.


Added to the mix is PECOS-the Provider Enrollment, Chain, and Ownership System, which is the on-line system that can be used to file and/or update the various CMS-855 forms. CMS is making strides in improving this system and also providing periodic updates to the database of providers and suppliers already registered. While embarrassing, you may not know for certain exactly what information is on file with Medicare let alone whether you are in PECOS.  Now is the time to find out!


Time to Focus


At this point, the main concern for all providers and suppliers is to ensure that the right person(s) (the one or ones with the knowledge and understanding of your organization) revalidates and updates these forms.  Yes, these forms must be updated within specific time periods.  For changes in ownership or management (e.g., board members), the time limit is 30 days.


Also, through the Affordable Care Act (ACA) there are now risk levels for various providers and suppliers.  Physicians and hospitals are generally in the low risk category with initially enrolling home health agencies and durable medical equipment (DME) suppliers being in the high-risk category.  While CMS has not yet started fingerprinting and criminal checks for the high-risk category, this process will certainly come in the future.



While enrollment is not likely to become an issue for recovery audit contractors (RACs), certainly other governmental auditing entities will want to look at the accuracy of the information being provided through the CMS-855 process.  Conceivably, if there were significant deficiencies and/or inaccuracies in your enrollment information, recoupment of payments could be pursued.


Also, there are associated questions such as the provider-based rule reporting requirement and whether or not the CMS-855 forms address this additional compliance issue.


About the Author


Duane C. Abbey, Ph.D., CFP, is an educator, author and management consultant working in the healthcare area.  He is president of Abbey & Abbey, Consultants, Inc., which specializes in healthcare consulting and related areas.  His firm is based in Ames, Iowa.  Dr. Abbey earned his graduate degrees at the University of Notre Dame and Iowa State University.


Contact the Author




To comment on this article please go to editor@racmonitor.com


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Duane C. Abbey, PhD, CFP

Duane C. Abbey, PhD, CFP, is an educator, author, and management consultant working in the healthcare field. He is president of Abbey & Abbey Consultants, Inc., which specializes in healthcare consulting and related areas. His firm is based in Ames, Iowa. Dr. Abbey earned his graduate degrees at the University of Notre Dame and Iowa State University. Dr. Abbey is a member of the RACmonitor editorial board and is a frequent guest on Monitor Mondays.

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