Medicare Enrollment Screening Tools Reviewed By OIG

The Centers for Medicare & Medicaid Services (CMS) views the enrollment process as an important gatekeeping tool for preventing fraud, waste and abuse. The passage of the Affordable Care Act (ACA) enhanced the ability of CMS to further this goal. Recently, the Office of the Inspector General (OIG) published a report analyzing the effectiveness of certain enhanced provider enrollment screenings.


The ACA authorized CMS to place providers into risk screening categories (high, moderate, low), expanded site visit requirements, and implemented the fingerprinting requirements which allows the agency to conduct a national background and criminal history record checks (the latter is reserved for owners of providers in the high-risk category). Under certain circumstances, moderate or low risk providers may be redesignated as “high risk” (e.g. conviction of certain crimes within the previous 10 years). CMS has also expanded its revalidation efforts.

Additionally, CMS relies on new screening tools, such as Automated Provider Screening, that checks certain application information against government records and raises red flags when information does not match (e.g., expired license).

OIG Finding

OIG compared enrollment data one year before the implementation of the enhanced screening requirements with data one year following the implementation. (2010-2011 v 2012-2013).

In the year after implementation of enhancements, providers submitted 12 percent (67,801) fewer enrollment applications. OIG views this decrease as evidence of a “deterrent effect” resulting from the enhanced enrollment screening process.

OIG could not conclusively determine whether the new Medicare enrollment enhancements prevented a greater percentage of ineligible providers from entering the program. The OIG found, however, that the number of Medicare revocation and deativations increased as a result of CMS’ revalidation effort. Furthermore, the OIG found that the “MACs revoked and deactivated a greater percentage of limited-risk providers than higher risk providers, even though these limited-risk providers were not subject to all of the new screening enhancements.”

As of May 2015 the billing privileges of more than 470,000 providers had been deactivated and those of almost 28,000 had been revoked.

OIG also found that although required the MACs did not always verify all of the information on provider enrollment or revalidation applications. Additionally, OIG found inconsistencies between site visit results and enrollment determinations which “raise questions about whether MACs always consider site visit results when making enrollment and revalidation decisions and whether valid and accurate address information is being used for site visits.”

OIG advised CMS to address the gaps in CMS’s verification process.

If you have questions about the OIG report, enrollment, revalidation, change of information, revocation, deactivation or have other health law questions, please contact our office.