Credentialing: Medicare and Medicaid Revalidations

 In Articles, Credentialing

Both Medicare and Medicaid require revalidation every three years for all individuals and entities enrolled in their programs. Each program launched a massive notification campaign last year. MSOC Health is here to point out the major roadblocks to the process, offer some advice for avoiding or overcoming them, and provide resources to make the revalidation process a little less painful. If you do not successfully revalidate, you can be terminated from the programs. Termination can lead to severe revenue loss depending on the size of your Medicare and Medicaid patient populations.

Roadblock #1 – Outdated Contact Information: One of the main problems we have encountered is the revalidation request going to an invalid address (physical or electronic). If you haven’t updated your information with Medicare in the past 3 years but you have moved, changed your correspondence address, or the person who handled your enrollment left your practice, there is a good chance that your revalidation letter will go out into the great blue yonder. Also, if a provider was initially enrolled in the Medicare or Medicaid program by a former practice, their individual revalidation letter may go to that old practice instead of to you. If you do not even know that it is time to complete revalidation, the provider or group can be terminated without your knowledge.

How can you avoid this?  If you think you might fall into any of these categories, update your correspondence and contact information with Medicare and Medicaid NOW. Do not wait until you are facing termination from the program because the letter was sent but you never got it. Don’t forget to update both the individual information and the practice information.

Provider update forms for each carrier are found on the CMS website for Medicare and your state’s Medicaid website.

How do you know if a letter has been sent for a provider or practice?  Unfortunately, there is no way to know with Medicaid, but Medicaid is quite persistent. If the emails and mailed letters are not responded to, Medicaid representatives start making phone calls. Medicare, on the other hand, does publish on the CMS website a listing of all letters mailed. It is a huge file that is posted by mailing month. You can download the file and search for your NPI(s). The website is: http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/Revalidations.html

Roadblock #2 – Multiple Provider Numbers:  There are instances when it is appropriate to have multiple provider numbers on file with Medicare and Medicaid, but when you have numbers on file that should have been terminated, they become roadblocks at revalidation.

Medicare assigns an individual PTAN (provider transaction number) for each practice that the provider is/has been affiliated with. When a provider leaves a practice, he or she should be terminated from that practice. The termination paperwork, however, is often never submitted and when revalidation time comes, a provider might have several PTANs that a current practice may not even be aware of. The current practice cannot terminate a prior affiliation without the former practice signing off on the paperwork (the CMS-855R form). Without all information on all active PTANs for an individual provider, Medicare will not accept the provider’s revalidation application and the provider may be suspended or terminated altogether from Medicare.

What to do?  When a new provider joins your practice, make sure you have a list of all prior employers and get the administrative contact for each. You can work with that contact to terminate the provider with Medicare from that practice. If you do this up-front, you won’t have to deal with old numbers at revalidation. If you’re already at the point of revalidation, you must go back in time and track down those contacts to obtain the individual and group PTANs as well as the prior practices tax identification numbers. If you cannot find a contact, the provider him or herself is the only one that can request a listing of the numbers on file with Medicare. Even then, Medicare will only mail a letter to the provider, and see Roadblock #1 above for issues with letters.

Medicaid only assigns one provider number per person. That one number may then be linked to multiple groups. The real roadblock comes with the group provider numbers. Medicaid assigns a different group number to each location of the practice. As your practice moves locations or adds new locations, you receive a new group provider number with Medicaid.

What to do?  Be sure you know what all of your numbers are. North Carolina Medicaid publishes all provider numbers on their website, and you can search for them by the number itself or by your NPI numbers. You can find all of the provider numbers associated with your NPI(s) on this site: http://www.ncdhhs.gov/dma/WebNPI/default.htm  If you have numbers that aren’t valid any longer, notify Medicaid to terminate them.

Roadblock #3 – Cost: There is no cost associated with revalidating physicians and practices with Medicare. A DME Supplier, however, must pay Medicare $523 to revalidate. And both individuals and practices must pay North Carolina Medicaid a $100 application fee to revalidate. Note that each practice location must revalidate. If you have three locations on file with Medicaid and five providers, it will cost a total of $800 to revalidate everything with Medicaid.

What to do?  If you want to maintain your status as a DME Supplier with Medicare or as a NC Medicaid provider, you must pay the fee. If you are considering dropping either of these programs though, the revalidation request letter might be your catalyst. Closely weigh the revenue you receive from the program before choosing to drop out. MSOC Health is happy to assist you with an analysis.

In summary, to avoid painful revalidations, keep your information up to date with the government. As a provider or practice administrator, demand that your administrative staff, at all practices and hospitals you work with, take the time to comply with all reporting rules for Medicare and Medicaid. If done correctly, your revalidations should be smooth and easy. MSOC Health completes the revalidation processes for all clients and maintains all information as changes are made.

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