Over the past couple years, our firm has received a number of calls from providers (including practices and individual physicians) having trouble with their Medicare revalidations. The influx of Medicare revalidation requests is a result of the new provider screening requirements implemented pursuant to the Affordable Care Act (ACA). Prior to the ACA, providers were instructed to revalidate their Medicare enrollment records only if, and when, requested. Now, each provider has a due date (once every 5 years) on which it must revalidate its Medicare enrollment records. Although the provider should receive a notice from its Medicare Administrative Contractor (MAC) to submit such revalidation application, the obligation is on the provider to know their due date and have the revalidation application submitted by then (regardless of MAC notice).
A provider’s responsibility is not complete upon submission of the application however. It is rare that a provider’s revalidation application is completely correct on the first submission. Pursuant to Medicare regulations, providers are obligated to respond to any correspondence from their MAC to submit additional information for the revalidation. Failure to do so within the timeframe allotted (i.e., 30 days) could result in payment withholds or deactivation of the provider’s Medicare billing privileges. If a provider’s billing privileges are deactivated, he/she/it will be required to re-enroll in Medicare and all claims between deactivation and re-enrollment will be denied. Although providers have the opportunity to challenge the deactivation or appeal the re-enrollment effective date, the provider must have a legitimate claim for such challenge/appeal and even then, there are no guarantees.
It is for this reason that it is critical that providers have a reliable system in place to: (1) track its practice’s and physicians’ revalidation due dates and (2) look out for and respond to any communications from the MAC regarding revalidation, or requests for additional information. That said, things happen and the provider’s Medicare billing privileges may be deactivated for reasons beyond his/her/its control (i.e., did not receive a request for additional information). In such instances, it is critical that a challenge to the deactivation be submitted as soon as the deactivation notice is received, and the re-enrollment application be submitted as soon as possible to limit any period of non-payment of claims. It is also recommended that providers reach out to a healthcare attorney at such time to assist in challenging the deactivation and to prepare them in the event that an appeal becomes necessary.
If you or your practice has encountered a revalidation issue and would like our firm’s assistance, please contact our office.