Medicare Revalidation – What is it and Why do we do it?

“Why do we have to do this?”

Five years ago Medicare suppliers and providers received the wonderful gift called Medicare Revalidation. Since that time, our billing office has been asked the same question over and over.

“Why do we have to do this?”

Well, a simple question begs a not so simple answer…so here goes. We’re going to use this space both this week and next week to help educate all of you about this process.

Medicare Revalidation – What is it and Why do we do it?Oh, and by the way, if you’ve received a revalidation notice…take action now! If you use our billing office connect with us right away- don’t wait. Chances are we’ve already reached out to you to gather the documents and information we need to assist in completing the revalidation application, so please reply because there is a deadline and it’s not negotiable.


One of the reasons for the Medicare revalidation process is to insure that all health care providers (individuals and groups) are registered in the master database called PECOS (Provider Enrollment Chain and Ownership System.) Many years ago, each Medicare “carrier” as they were called back when, maintained a separate database of providers and there was little ability for cross-checking and verification of information across those carrier lines.

Today, carriers are Medicare Administrative Contractors (MAC) and each MAC is partitioned into Jurisdictions or geographic chunks of States where they act on behalf of CMS to administer the Medicare program. These MACs, however, all use PECOS to interconnect and share information across the Medicare system. Now, information about a provider or supplier who once billed Medicare in New York City can be instantly compared with the same provider info should that provider move operations to Los Angeles. This especially comes in handy if CMS is trying to identify individuals or group practices (such as ambulance services and owners/administrators of those ambulances) who may have committed fraud and abuse in one area and now is trying to re-apply under assumed names/aliases, etc. to bill fraudulently again but only in a new geographic location.

The revalidation process will once and for all require all providers to be entered and registered into the PECOS system.

Combating Fraud and Abuse using On-Site Inspections

The revalidation process insures that all provider address locations be verified as legitimate practice locations. This is the reason why CMS and the MAC’s are so picky about the physical office/station/practice addresses complete with a Zip +4 designator in order that a site inspector can visit each location to complete the revalidation verification process.

This step insures that there are no bogus store-front operations set up as cover-ups where real services are not provided. Too many illegitimate health care providers can set up shop in some strange non-active location with money flowing to a remote Post Office Box. Prior to this process, a new ambulance company group provider could have potentially set-up a store-front, strip mall address and report claims billed fraudulently using ambulance vehicles that were sitting in some junk yard somewhere and for services never provided.

As entitlement programs such as Medicare edge nearer to feared insolvency, this is one method that that Congress and CMS has come up with to verify the identity of provider, groups and their owners and administrators prior to paying any further or initial claims.

Is it time…?

Is it time to revalidate?

Our billing office monitors the CMS revalidation site on a weekly basis to insure that we do not miss a revalidation deadline. Additionally, the MACs send out communication letters reminding you of your organization’s revalidation date. The date is also anchored to exactly every five years. Once you have completed revalidation for your EMS agency you will only be required to report changes, but a full revalidation is not necessary in between the fire-year timeframe.

But, be sure to NOT miss the deadline.

Missing the deadline and failing to revalidate will result in suspension of your Medicare payments and eventually cause you to lose your Medicare billing privileges. Once your Medicare Provider Transaction Access Number (PTAN) has been deactivated, no claims will be paid retroactively. This means that any transport you provide to a Medicare beneficiary between the date that your organization’s PTAN is deactivate until the time your revalidation application is approved and you are re-credentialed cannot be paid by the MAC. Your organization loses reimbursement within that timeframe.

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