The Costly Pitfalls of Missing Out on Medicare Revalidation

In the last six weeks, my colleagues and I have dealt with two situations in which clinics either missed or did not receive the orange envelope containing their revalidation materials.

They didn’t respond, and the consequences are brutal. Their Medicare numbers were deactivated, and they now have potentially irreversibly lost the ability to bill hundreds of thousands of dollars’ worth of services.

In other words, Medicare revalidation is a really big deal. 

Most Medicare providers and suppliers have to revalidate every five years, though Durable Medical Equipment, Prosthetics and Orthotics Suppliers (DMEPOS) revalidate every three years.

The Centers for Medicare & Medicaid Services (CMS) is also empowered to require an off-cycle revalidation. Navigating the revalidation process is remarkably difficult, and I won’t purport to be an expert in it.

While there is a lookup tool that allows you to determine when you are supposed to revalidate, it doesn’t just include every organization and the date that they will revalidate. Instead, it has a rolling list of organizations that will revalidate over the next seven months. If you are not due to revalidate in that seven-month window, or you missed your revalidation, you won’t see your organization or professional there. 

CMS does typically try to contact you to notify you of revalidation. The letter or email will be sent to an address currently listed in the Provider Enrollment, Chain, and Ownership System (PECOS). It is far too common for organizations to have outdated enrollment information with CMS, and having the wrong address on file is a common cause of revalidation failures. 

CMS asserts that it will send a notice to you via email or mail about three or four months before your due date. But any mailed notice does not come certified, and we all know the issues that can arise with an email. There is absolutely no guarantee you will receive it. They expect you to know your revalidation date, and the government doesn’t believe that failure to receive the notice is a justification for missing a revalidation. 

This is exactly the sort of ministerial task that can seem rather insignificant, but result in catastrophic consequences to your organization. The situation last week involved my colleague explaining to one of our clients the very real risk that this small clinic may lose $750,000 in reimbursements because of a seemingly minor paperwork snafu.    

To lower your risk, there are a few things you can try. First, check the Medicare revalidation list to see if you have any revalidations coming up in the near term. Next, look at PECOS and make sure your enrollments are all current and have the right address.

Then I would figure out what your revalidation date is likely to be, and have multiple calendar entries with multiple people, all of whom will check to make sure your enrollment is extended. Don’t assume you will receive a notice, because it may be sent to the most senior member of the group, who just retired recently, or your enrollment professional who isn’t doing reliable work.

Or it may just get lost in the shuffle. It can easily become one of the more expensive small errors you will ever make.