Protecting the integrity of the Medicare program is a top priority.  Fortunately, the Affordable Care Act has allotted significant funding for task forces to root out fraud, waste and abuse. Up until now, the task forces have focused recovery efforts on funds already paid to the providers and suppliers.  The new focus is on prevention of fraud before it occurs.  To that end, in order to identify providers at high risk for committing fraud, the Center of Medicare and Medicaid Services (CMS) will be increasing provider and supplier enrollment screening.

A recent announcement by Shantanu Agrawal, M.D., CMS Deputy Administrator and Director at the Center for Program Integrity, outlines the following four specific targets for enrollment screening:

  • Increase the number of site visits to Medicare-enrolled providers and suppliers

CMS will most likely visit providers in high- risk geographic areas (Miami, Tampa, Baton Rouge, Los Angeles, Detroit, Brooklyn, Houston, Dallas and Chicago) and those providers with very high Medicare reimbursement levels.  The on-site review may include verification of enrollment information as well as compliance with Medicare enrollment requirements. (See §42 C.F.R 424.517).

  • Enhance address verification software in PECOS to better detect vacant or invalid addresses or commercial mail receiving agencies (CMRAs)

This new software will include Delivery Point Verification (DPV) which provides the highest level of address checking.  This added function will likely deter those individuals who bill Medicare for services from a non-existent entity and identify use of CMRA, which is a mail drop that is generally not allowed by Medicare.

  • Deactivate providers and suppliers that have not billed Medicare in the last 13 months.

On a monthly basis, the enrollment data will be analyzed and those providers and suppliers who have not billed Medicare in the last 13 months will be deactivated.  Exemptions for non-billing include those who are only enrolled to order, refer or prescribe and a few specialties such as dentists and pediatricians.

  • Monitor and identify potentially invalid addresses on a monthly basis through additional data analysis by checking against the U.S. Postal Service address verification database

After initial enrollment, the business operation at a particular location may be defunct or may have relocated or may have always been vacant, but the address still remains within the PECOS database.  This additional analysis will use the USPS to determine if the locations are valid.  It is the responsibility and a condition of enrollment by the provider or supplier to inform CMS of any changes to their enrollment, including change of address.

These proactive measures of enrollment screening with site visits, improved software and continuous data analysis should help to prevent fraud before it occurs.