Data Transparency and the Extension of Temporary Provider Enrollment Moratoria (CMS 6059-N4)

By Shantanu Agrawal, M.D., CMS Deputy Administrator and Director, Center for Program Integrity

As part of our efforts to improve care delivery through the sharing and utilization of information, the Centers for Medicare & Medicaid Services (CMS) has released two new public data sets. A new public file provides information on the availability and use of services provided to Medicare beneficiaries by ambulance and home health agencies (HHAs), a second data set provides the list of all approved providers and suppliers in Medicare’s fee-for-service operations. Both data sets are available at https://data.cms.gov

The Affordable Care Act provided CMS with new opportunities and resources to combat fraud, waste, and abuse in Medicare, Medicaid, and the Children’s Health Insurance Program (CHIP).  CMS used authority provided by the Affordable Care Act to impose temporary enrollment moratoria for the first time on July 30, 2013 (Phase I) and for the second time on January 30, 2014 (Phase II).  CMS extended these six-month phases of the moratoria on July 29, 2014; January 29, 2015; July 29, 2015 and most recently on January 29, 2016. The moratoria temporarily halted the enrollment of new home health agencies (HHAs) and ground ambulance suppliers in certain geographic areas, and giving CMS the opportunity to analyze and monitor the existing provider and supplier base, as well as further focus additional fraud prevention and detection tools in these areas.

Today, as part of our efforts to share information, CMS released a Moratoria Provider and Supplier Services and Utilization Data Tool. The tool uses ambulance and HHA paid claims data within CMS systems for Medicare fee-for-service beneficiaries. The data, which do not contain any individually identifiable information about Medicare beneficiaries or their providers, cover the period from October 1, 2014 to September 30, 2015, and are updated quarterly.  The tool includes interactive maps and a dataset that shows national-, state-, and county-level provider and supplier services and utilization data for selected health service areas. For this first release, the data provide information on the number of Medicare ambulance suppliers and HHAs servicing a geographic region, with moratoria regions at the state and county level clearly indicated, and the number of Medicare beneficiaries who use one of these services. Users of the tool can also find the degree to which use of these services is related to the number of providers and suppliers servicing a geographic region. Provider and supplier services and utilization data by geographic regions are compared easily using the interactive maps. Future releases may include comparable information on additional health service areas.

CMS’ continued commitment to strengthening program integrity also extends to supporting the provider and supplier community through increased transparency about those enrolled in the Medicare program. As part of this effort, CMS is publishing Public Provider Enrollment Files that list all providers and suppliers enrolled in Medicare. The continued growth of programs that require provider and supplier enrollment in Medicare fee-for-service as a prerequisite has steadily increased, as has the demand for information from the healthcare industry. This public provider data allows users, including other health plans, and researchers the ability to access Medicare data.

The Public Provider Enrollment Files consist of individual and organizational enrollment information on all providers and suppliers nationwide who are approved to bill Medicare. This includes key unique identifiers, enrollment type and state, names, National Provider Identifier (NPI), specialty, and limited address information (City, State, Zip code). This data also identifies reassignment relationships between individuals and groups. The information in the file will be updated quarterly and extracted directly from the Provider Enrollment, Chain, and Ownership System (PECOS), which is the official system of record for Medicare fee-for-service enrollment. The information can only be updated through submission of updates to enrollment information via PECOS. Providers and suppliers will need to make enrollment updates by contacting their respective Medicare Administrative Contractor (MAC), or by going to https://pecos.cms.hhs.gov/. Updates will be shown with the next release of the file.

The long-term goal of this initiative is to continue to expand data elements available in the files, and eventually consolidate other existing public lists of provider information, such as the Ordering and Referring File, Part D Prescribing File, and Revalidation Lists. CMS believes the release of the enrollment data provides a clear and transparent way for providers, suppliers, state Medicaid programs, private payers, researchers, and other interested individuals or organizations to leverage Medicare Provider Enrollment information.

To view a fact sheet on the Ambulance and HHA data set, visit: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-02-22.html  The utilization tool is available through the CMS website at: https://data.cms.gov/moratoria-data

To view a fact sheet on the Public Provider Enrollment file, visit:  https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-02-22-2.html   This data set is available through a series of .csv files that will be updated quarterly and published at https://data.cms.gov/public-provider-enrollment.

Questions regarding the Public Provider and Supplier Enrollment files or the Ambulance and HHA data set should be sent to the Office of Communications at the Office of Communication, 7500 Security Blvd., Baltimore, MD 21244-1850.

CMS strengthens provider and supplier enrollment screening

By Shantanu Agrawal, M.D., CMS Deputy Administrator and Director, Center for Program Integrity

CMS is strongly committed to protecting the integrity of the Medicare program, including making sure only qualified providers and suppliers are enrolled in Medicare. The Affordable Care Act provided tools to enhance our ability to screen providers and suppliers upon enrollment and identify those that may be at risk for committing fraud, including the use of risk-based screening of providers and suppliers.  In addition to implementing the tools provided by the Affordable Care Act, we are strengthening our strategies designed to reinforce provider screening activities by increasing site visits to Medicare-enrolled providers and suppliers, enhancing and improving information technology (IT) systems, and implementing continuous data monitoring practices to help make sure practice location data is accurate and in compliance with enrollment requirements.

We have the authority to conduct site visits on all enrolling and enrolled providers and suppliers, and the Affordable Care Act gave us tools to enhance our ability to screen and identify those that may be at risk for committing fraud.  A recent Government Accountability Office (GAO) report, which identified areas for improvement in our Provider Enrollment, Chain, and Ownership System (PECOS) – the IT system for Medicare enrollment – regarding verification of provider or supplier practice locations, helped CMS target our efforts to further enhance our provider screening activities. We appreciate the GAO’s work in this area and are using the GAO’s findings to support our broader provider screening enhancements

When enrolling in Medicare, providers and suppliers (including physicians and non-physician practitioners) are required to supply on their application the address of the location from which they offer services. As a result of our continuous review of policies, we have put into practice four tactics to strengthen strategies designed to reinforce provider and supplier screening activities:

Increase the number of site visits to Medicare-enrolled providers and suppliers. CMS has the authority, when deemed necessary, to perform onsite review of a provider or supplier to verify that the enrollment information submitted to CMS or its agents is accurate and to determine compliance with Medicare enrollment requirements (42 C.F.R. 424.517). Under this authority, CMS has increased site visits, initially targeting those providers and suppliers receiving high reimbursements by Medicare that are located in high risk geographic areas.

Enhance address verification software in PECOS to better detect vacant or invalid addresses or commercial mail reporting agencies (CMRAs). Starting this year, CMS will replace the current PECOS address verification software with new software that includes Delivery Point Verification (DPV) in addition to the existing functionality. This new DPV functionality will flag addresses that may be vacant, CMRAs or invalid addresses. In most cases, CMRAs are not permitted in the Medicare program. These verifications will take place during the application submission process and may trigger additional ad hoc site visits.

Deactivate providers and suppliers that have not billed Medicare in the last 13 months. Beginning March 2016 and on a monthly basis, CMS will run analysis on enrollment data to deactivate providers or suppliers meeting specific criteria that have not billed Medicare in the last 13 months. Providers and suppliers that may be exempted from the deactivation for non-billing include: those enrolled solely to order, refer, prescribe; or certain specialty types (e.g., pediatricians, dentists and mass immunizers (roster billers)). This approach will remove providers and suppliers with potentially invalid addresses from PECOS without requiring site visits. 

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. CMS has started to continuously monitor and identify addresses that may have become vacant or non-operational after initial enrollment. This monitoring is done through monthly data analysis that validates provider and supplier enrollment practice location addresses against the U.S. Postal Service address verification database.

If you are a provider or supplier, you can help us protect the integrity of the Medicare program by informing us promptly of any changes to your enrollment, as required.

We are committed to protecting the integrity of the Medicare program. Increasing site visits, improving IT systems, and conducting continuous data monitoring will strengthen the integrity of the Medicare program while minimizing burden on the provider and supplier community.

A guide for new and first-time physicians participating in federal healthcare programs

By Shantanu Agrawal, MD

With a new class of medical residents beginning their training, and residents and Fellows graduating from their programs every July, it’s important that our critical partners in the delivery of healthcare have the tools they need to understand federal program requirements.  At the Centers for Medicare & Medicaid Services (CMS) we have a comprehensive strategy to reduce fraud, waste and abuse that is designed to target risk – that means as we make it harder for bad actors to enroll or bill in our systems, we are always evaluating how to make it easier for legitimate physicians and other providers to participate in Medicare and care for beneficiaries.

CMS demonstrates this commitment with several initiatives:

  • Providers enrolling in Medicare for the first time now have a much easier experience enrolling than in years past. Since 2012, paper is no longer required to complete an application.  Everything can be submitted online, using web-based “PECOS” (the Provider Enrollment, Chain and Ownership System – the official record of every provider in Medicare). That includes required signatures and attachments, such as medical licensure. If an application fee is required – typically owed by organizations – it can also be paid online. The conveniences of the web-based PECOS system allow for faster application processing times over paper-based applications.
  • We recently launched two free mobile applications for Apple iOS and Android devices to help various stakeholders comply with the new requirements of the Open Payments program (commonly known as the Physician Payments Sunshine Act). This program tracks financial relationships between covered physicians and the health care industry – such as pharmaceutical and medical device companies – and will make the data available to the public annually on a website currently being designed. Physicians are not required to report any data, but the mobile applications will help them to track financial relationships and assess reported data for accuracy.
  • CMS is also modernizing how we communicate with physicians. We are now using Facebook / Facebook4 and Twitter / Twitter10 to keep tech-savvy providers up-to-date on the latest CMS news and progress being made.  Use these resources to engage and share your comments on our program efforts via Email and Google.
  • At CMS we also know the risks and challenges that many new physicians face in today’s healthcare landscape. We are dedicated to helping new physicians stay on track with important updates in our Medicare and Medicaid operations. That’s why the Center for Program Integrity is making it easier for physicians to resolve issues of identity theft. We’re providing information on how to protect your medical identity, numerous educational toolkits and Continuing Medical Education (CME) on CMS program integrity activities.

New and practicing physicians should note that as CMS shifts its fraud-fighting strategy to become more proactive, people committing fraud are doing the same. In our long-running patient education programs, we have provided ways patients and their families can spot and prevent scams. And we are developing more fraud-focused materials for health care providers and suppliers.

New physicians are emerging as a new vulnerability because of their inexperience with federal programs, financial obligations resulting from medical school, and aggressive scammers skillfully crafting schemes that appear to be legitimate.

New doctors should be aware of job offers that appear “too good to be true.” As with any other professional offer received or found — in print, on the internet, or other reputable or often-used resources – please be wary of offers that pay large sums of money in exchange for reviewing medical records written by others. Most often these include night and weekend work offers for your professional services to assist home health and durable medical equipment operations, usually off-site.

For Medicare fraud scams, they will require that you enroll or be enrolled in Medicare or PECOS. Never accept money or gifts for work you did not perform. Scammers that are offering cash for your participation in fraud are quick to disappear and have no issue with leaving you out to dry. Convictions for certain health care fraud violations will result in exclusion from federal healthcare programs – and potentially preventing your participation in certain State Medicaid programs and private health plans. Remember, the penalties are much larger than any short-term benefit.

To help new physicians develop defenses against these scams, CMS urges you to:

And most importantly, all doctors and their patients should report fraud as soon as it is suspected to the HHS Office of Inspector General. Tips can be reported either online or by phone at 1-800-HHS-TIPS. It’s never too late to report information, and by doing so you will be joining the fight to protect federal healthcare programs for future generations.

Shantanu Agrawal, M.D., is the Medical Director for the Center for Program Integrity at the Centers for Medicare & Medicaid Services.

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