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Enhanced Enrollment Screening of Medicare Providers: Early Implementation Results

Tanaz Dutia, a team leader for the Office of Evaluation and Inspections, is interviewed by Linda Ragone, Regional Inspector General for the Office of Evaluation and Inspections in Philadelphia.

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[Linda Ragone] I'm Linda Ragone, Regional Inspector General for the Office of Evaluation and Inspections in Philadelphia. I'm speaking with Tanaz Dutia, a team leader in our office to discuss the recent report on the enhancements made to the Medicare enrollment screening process for providers and suppliers. Tanaz, what are the new enhancements to the enrollment process?

[Tanaz Dutia] The Affordable Care Act gave the Centers for Medicare and Medicaid Services, or CMS, new tools to combat fraud by enhancing the enrollment screening process. Before that, there were a few providers that were required to have a site visit as part of the enrollment process. For this study, we looked at increasing site visits for moderate and high risk providers. For example, CMS now requires that ambulance companies and home health centers have a site visit, when in the past it wasn't required.

[Linda Ragone] Tell me why the Medicare enrollment process is important?

[Tanaz Dutia] Sure. You can think of the enrollment process as a gateway that a provider or supplier goes through before being able to bill Medicare. This gateway should be strong enough to prevent corrupt providers and suppliers from ever being able to bill Medicare. The enhancements we looked at are designed to stop fraudulent providers and suppliers from being able to steal from Medicare and its beneficiaries.

[Linda Ragone] In general, how does a provider or supplier enroll in Medicare?

[Tanaz Dutia] A provider or supplier has to submit an enrollment application to a Medicare Administrative Contractor, called a MAC, or the National Supplier Clearinghouse, called NSC. They can mail in a paper application or apply on-line. The MAC or NSC reviews the application and orders a site visit if it is required. Then they determine whether the provider or supplier is eligible to enroll in Medicare. After a provider or supplier is enrolled, they must revalidate their enrollment every few years.

[Linda Ragone] Did your work focus on any other enhancements?

[Tanaz Dutia] Yes. The Affordable Care Act required CMS to revalidate all existing providers' and suppliers' enrollment using the new enhancements.

[Linda Ragone] What was the impact on enrollment and revalidation?

[Tanaz Dutia] Well, after the enhancements, there were fewer enrollment applications submitted. There were also more incomplete applications returned to providers, and a higher rate of approvals (and a lower rate of denials) among Medicare applications with enrollment determinations.

[Linda Ragone] Were you able to draw any conclusions about the enhancements?

[Tanaz Dutia] With the variation in data, we couldn't determine conclusively if the enhancements stopped more ineligible providers from entering Medicare. On the other hand, when CMS revalidated existing enrollments, there were substantial revocations and deactivations of providers' billing privileges.

[Linda Ragone] Did you find any problems with how contractors reviewed enrollment and revalidation applications?

[Tanaz Dutia] Yes, we found gaps in the way contractors' verified key information on applications, like identification numbers and criminal convictions. That could leave the program vulnerable to approving providers or suppliers that submitted false information.

[Linda Ragone] You also found some issues regarding site visits. Can you explain?

[Tanaz Dutia] We found that MACs approved hundreds of applications despite site visits that weren't in compliance with Medicare standards. There were also discrepancies in how contractors conducted site visits and used the results. For example, site visit inspectors answered "Yes" to a question about whether patients or customers were seen at the facility, yet the inspectors' additional comments indicated that they didn't see any patients or customers. In other cases, a number of inspectors reported that they did not receive training on how to determine if a facility is operational.

[Linda Ragone] So can CMS tell us if the enhancements are making a difference?

[Tanaz Dutia] We found that CMS can't use existing data to determine the impact of the enhancements on provider enrollment. This is because its systems don't have all of the information needed for effective oversight. For instance, CMS did not consistently maintain data on application denials or the reasons providers submitted applications.

[Linda Ragone] What recommendations did you make in your report?

[Tanaz Dutia] We made five recommendations to CMS. First, CMS should monitor contractors to determine if they properly verify information on enrollment and revalidation applications. Second, CMS should confirm that contractors are appropriately using site visit results when making enrollment decisions. Third, CMS should revise and clarify site visit forms so that they can be more easily used by inspectors to determine if a facility is operational. Fourth, CMS should require the National Site Visit Contractor to improve quality-assurance oversight and training of site visit inspectors. And lastly, CMS should make sure its enrollment data system has the complete and accurate data to evaluate its enrollment-screening enhancements.

[Linda Ragone] How did CMS respond to your report's recommendations?

[Tanaz Dutia] CMS agreed with all five of our recommendations.

[Linda Ragone] Thank you, Tanaz, for sharing this important work on Medicare provider and supplier enrollment.

[Tanaz Dutia] Thank you, Linda.