Enhanced Enrollment Screening of Medicare Providers: Early Implementation Results

WHY WE DID THIS STUDY

To bill for services they provide to beneficiaries, providers must enroll in Medicare and periodically revalidate this enrollment. Effective enrollment screening is an important tool in preventing Medicare fraud. The Centers for Medicare & Medicaid Services (CMS) has sought to enhance the enrollment screening process with new antifraud tools such as placing providers in risk categories, increasing site visits, requiring fingerprinting, implementing an Automated Provider Screening system, and denying enrollment to providers whose owners have unresolved overpayments. This study examines CMS's early implementation of new screening tools intended to prevent illegitimate providers from enrolling in Medicare.

HOW WE DID THIS STUDY

We obtained data from CMS on enrollment and revalidation applications submitted for the 1-year period before the implementation of enhanced screening procedures (i.e., March 25, 2010, through March 24, 2011) and the 1-year period after the implementation of enhanced screening procedures (i.e., March 25, 2012, through March 24, 2013). For the latter period, we reviewed detailed results of 16,022 site visits conducted by CMS's National Site Visit Contractor (NSVC). In addition, we examined CMS's and its contractors' policies and procedures for enrollment, and we surveyed or interviewed CMS and contractor staff involved in the enrollment process.

WHAT WE FOUND

After CMS implemented risk screening and site visit enhancements to strengthen the provider enrollment process, we found that providers submitted fewer enrollment applications to CMS in the postimplementation period. There was also an increase in the rate of applications that CMS returned to providers and a higher rate of approvals (lower rate of denials) among CMS's enrollment determinations. Given the variation in outcome statistics, it is not possible to determine conclusively whether the enhancements prevented a greater percentage of ineligible providers from entering Medicare. However, CMS's additional efforts to revalidate all existing enrollments yielded substantial revocations and deactivations of existing providers' billing privileges. The revalidation process resulted in a much higher percentage of providers being deactivated than revoked. Additionally, we found that CMS's implementation of enhanced enrollment screening needs strengthening. Our review found gaps in contractors' verification of key information on enrollment applications that could leave Medicare vulnerable to illegitimate providers. In addition, contractors were inconsistent in applying site visit procedures and using site visit results for enrollment decisions. Finally, CMS's enrollment data system does not contain the information needed for effective oversight and evaluation of the enhancements to the enrollment screening process.

WHAT WE RECOMMEND

We recommend that CMS (1) monitor contractors to determine whether they are verifying information on enrollment and revalidation applications as required; (2) validate that contractors are appropriately considering site visit results when making enrollment decisions; (3) revise and clarify site visit forms so that they can be more easily used by inspectors to determine whether a facility is operational; (4) require the NSVC to improve quality-assurance oversight and training of site visit inspectors; and (5) ensure that CMS's enrollment data system contains the complete and accurate data needed to execute and evaluate CMS's enrollment-screening enhancements. CMS concurred with all five of our recommendations.