Department of Health and Human Services 
OFFICE OF 
 
INSPECTOR GENERAL 
 
 
 
 
 
E E
N  HANCED  NROLLMENT 
 
S M
C  REENING OF  EDICARE 
 
P : E
  ROVIDERS    ARLY 
 
I R  
MPLEMENTATION  ESULTS
 
 
 
Daniel R. Levinson 
Inspector General            
 
April 2016 
OEI-03-13-00050   
EXECUTIVE SUMMARY ENHANCED ENROLLMENT SCREENING OF MEDICARE 
PROVIDERS:  EARLY IMPLEMENTATION RESULTS   
OEI-03-13-00050 
 
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 CMSs 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 CMSs National Site Visit Contractor (NSVC).  In addition, we 
examined CMS 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 CMSs 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, CMSs 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 CMSs 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, CMSs 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 CMSs enrollment data system contains the complete and accurate 
data needed to execute and evaluate CMSs enrollment-screening enhancements.  CMS concurred 
with all five of our recommendations.  
 
 
TABLE OF CONTENTS 
 
Objectives ....................................................................................................1 
Background ..................................................................................................1 
Methodology ................................................................................................6 
Findings........................................................................................................8 
Providers submitted fewer enrollment applications after CMS 
implemented risk-screening and site visit enhancements ................8 
CMSs effort to revalidate all existing enrollments yielded  
substantial revocations and deactivations ......................................10 
Key provider information is not verified during the enrollment or 
revalidation processes .................................................................... 11 
Contractors were inconsistent in applying site visit procedures     
and using site visit results for enrollment decisions ......................12 
CMS relies on an enrollment data system, PECOS, that does not 
contain all the information needed for effective oversight ............15 
Conclusion and Recommendations ............................................................18 
Agency Comments and Office of Inspector General Response .....21 
Appendixes ................................................................................................22 
A:  General Site Visit Form ...........................................................22 
B:  Number of Contractors That Verify Identification Numbers 
Submitted by Providers on Enrollment and Revalidation 
Applications ...................................................................................23 
C:  Agency Comments ...................................................................25 
Acknowledgments......................................................................................28 
   
 
OBJECTIVES 
1.  To examine how CMS and its contractors implemented enhanced 
screening procedures for enrolling and revalidating Medicare providers 
and suppliers. 
2.  To review the early results of enhanced screening procedures on the 
enrollment and revalidation of Medicare providers and suppliers.  
BACKGROUND  
Providers and suppliers must enroll in the Medicare program and 
periodically revalidate their enrollment to be eligible to bill Medicare.  
CMS has stated that provider enrollment is the gateway to Medicare.1  If 
this gateway is not adequately safeguarded, Medicare is at increased risk of 
enrolling providers and suppliers with intent to defraud the program.  
Effective enrollment screening is an important tool in preventing Medicare 
fraud.   
Since 1997, the Office of Inspector General (OIG) has identified numerous 
vulnerabilities regarding provider and supplier enrollment and has made 
recommendations for improvement.  In an effort to combat fraud, waste, 
and abuse resulting from vulnerabilities in the enrollment process, CMS 
has sought to enhance enrollment screening with a set of new tools.  These 
tools include new antifraud authorities provided by the Patient Protection 
and Affordable Care Act (ACA), an Automated Provider Screening (APS) 
system, and the ability to deny enrollment to providers and suppliers with 
unresolved overpayments.2, 3        
Enrollment and Revalidation Applications 
Providers and suppliers submit paper or electronic applications to Medicare 
Administrative Contractors (MACs) or to the National Supplier 
Clearinghouse (NSC) when newly enrolling in Medicare, changing their 
information, and reactivating or revalidating their enrollment.4  CMS 
contracts with MACs and the NSC to review these applications and 
determine whether providers are eligible to bill Medicare.  In accordance 
 
1 CMS, CMS Proposes New Safeguards and Incentives to Reduce Medicare Fraud,  
April 24, 2013.  
2 P.L. No. 111-148 (Mar. 23, 2010), as amended by the Health Care and Education 
Reconciliation Act of 2010, P.L. No. 111-152 (Mar. 30, 2010). 
3 A Medicare overpayment is a payment that a provider or supplier received in excess of 
amounts properly payable under Medicare statutes and regulations. 
4 The NSC processes applications for suppliers of durable medical equipment, prosthetics, 
orthotics, and supplies (DMEPOS).  MACs process all other applications.   
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  1 
   
 
with the Medicare Program Integrity Manual, MACs and the NSC must, 
unless otherwise specified, verify and validate all information furnished by 
providers on CMS-855 application forms.     
There are five CMS-855 enrollment application forms for the following 
broad categories of providers: 5   
  institutional providers (CMS-855A); 
  clinics, group practices, and certain other suppliers (CMS-855B); 
  physicians and nonphysician practitioners (CMS-855I);  
  suppliers of Durable Medical Equipment, Prosthetics, Orthotics, 
and Supplies (DMEPOS) (CMS-855S); and 
  ordering and referring providers (CMS-855O). 
Applications submitted to newly enroll, change information, or reactivate 
enrollmenthereinafter, enrollment applicationsmay be:  
  approved, i.e., determined to be eligible to bill Medicare or  
  denied, i.e., determined to be ineligible to bill Medicare.  
In other instances, MACs or the NSC may return an enrollment application to 
a provider if that provider furnished incomplete information during the 
application process. Providers can also withdraw their applications at any 
time during the process. 
After providers initial enrollment, CMS requires them to revalidate their 
enrollment after a certain number of years.  DMEPOS suppliers are 
required to revalidate their enrollment every 3 years.  All other providers 
are required to revalidate every 5 years.  Revalidation applications may be  
  approved,  
  revoked, i.e., billing privileges are terminated, or  
  deactivated, i.e., billing privileges are stopped but can be restored 
upon submission of updated information. 
The Provider Enrollment, Chain, and Ownership System (PECOS) is 
CMSs repository for provider enrollment information.   
Enhancements to the Enrollment-Screening Process 
The ACA provided CMS with the authority for enhancements to the 
enrollment-screening process, including, placing providers into risk 
screening categories, expanding site visit requirements, using fingerprints 
 
5 In this report we use the term providers to encompass both providers and suppliers. 
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  2 
   
 
to conduct national background checks and criminal history record checks, 
and expanding revalidation efforts.6   
In addition, CMSs APS system aims to automate and standardize the 
process by which MACs and the NSC verify application information.  
CMS also issued guidance to MACs and the NSC on denying enrollment to 
providers with unresolved overpayments.7   
Risk screening.  On March 25, 2011, CMS began assigning providers to 
one of three risk categories:  limited, moderate, or high risk.  Providers 
assigned to higher risk categories are subject to a more extensive review.  
Federal regulations outline which provider types are assigned to each risk 
category:   
  High risk:  newly enrolling home health agencies (HHAs) and 
newly enrolling DMEPOS suppliers; 
  Moderate risk:  ambulance service suppliers, community mental 
health centers, comprehensive outpatient rehabilitation facilities, 
hospice organizations, independent clinical laboratories, 
independent diagnostic testing facilities (IDTFs), physical therapists 
enrolling as individuals or group practices, portable x-ray suppliers, 
revalidating HHAs, and revalidating DMEPOS suppliers; and 
  Limited risk:  all other provider types. 8   
Providers initially designated as limited or moderate risk may be 
redesignated as high risk if they meet certain criteria, such as having been 
convicted of certain crimes within the previous 10 years.   
Site visits.  The ACA provided CMS with the authority to expand the provider 
types subject to site visits.9  Prior to the ACA, IDTFs and DMEPOS suppliers 
were subject to site visits as part of the enrollment process.10  In accordance with 
Federal regulations, all providers designated as moderate or high risk must 
undergo a site visit when newly enrolling, adding or changing a practice 
location, undergoing a change of ownership that results in a new tax 
identification number, reactivating, or revalidating enrollment.   
 
6 ACA  6401. 
7 CMS, Transmittal 479, Change Request 8039.  CMS Manual System, Pub. No. 100-08, 
Enrollment Denials When an Existing or Delinquent Overpayment Exists. 
8 42 CFR  424.518 
9 ACA  6401(a), codified at 42 USC  1395cc(j)(2)(B)(ii)(III). 
10 Prior to the ACA, certain DMEPOS suppliers did not receive site visits, including chains 
with 25 or more locations, physicians, hospitals, skilled nursing facilities, ambulatory 
surgical centers, physical therapists, occupational therapists, and managed care 
organizations.  After the ACA, all DMEPOS suppliers are subject to site visits. 
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  3 
   
 
The NSC performs site visits of DMEPOS suppliers.  For all other providers, 
CMS implemented a site visit process using a National Site Visit Contractor 
(NSVC).  MSM Security Services, Inc. serves as the NSVC.  The NSVC began 
performing site visits in late January 2012 and was fully operational on   
March 15, 2012.11  The NSVC and the NSC use three standard forms to conduct 
site visits depending on the type of provider visited.  The NSVC uses a 
specialized form for IDTFs and the NSC uses a specialized form for most 
DMEPOS suppliers.  For all other providers and certain DMEPOS suppliers, the 
NSVC and the NSC use a more general site visit form.12   
MACs and the NSC are responsible for reviewing the results of site visits prior 
to making final decisions regarding applications.  For applications screened with 
the general site visit form, the site visit determines whether  
  the facility is open, 
  personnel are at the facility, 
  customers are at the facility (if applicable to that provider or supplier 
type), and 
  the facility appears to be operational.13 
The general site visit form contains six closed-ended (i.e., Yes/No) 
questions and a section for additional comments from site visit inspectors.14  
Four of the questions each directly corresponds with one of the four 
standards noted above.  Appendix A contains the general site visit form.  The 
IDTF site visit form used during our review period contained 22           
closed-ended questions addressing the IDTF standards in 42 CFR  410.33 
and additional questions asking for specific information or explanations of 
responses.  The site visit form for DMEPOS suppliers contains 44 
closed-ended questions addressing the DMEPOS supplier standards in 42 
CFR  424.57.  The DMEPOS supplier site visit form has additional 
questions asking for specific information or explanations of responses.  
 
11 Prior to the ACA, MACs conducted site visits of IDTFs.  After the ACA, MACs 
conducted site visits for non-DMEPOS providers until the NSVC was fully operational. 
12 The general site visit form is used during enrollment and revalidation of the following 
DMEPOS suppliers:  chains with 25 or more locations; hospitals; skilled nursing facilities; 
professionals (excluding chiropractors); ambulatory surgical centers; physical and 
occupational therapists; and managed care organizations. The form also may be used for 
all DMEPOS suppliers to conduct site visits not associated with enrollment or 
revalidation, including site visits in response to complaints. 
13 CMS, Medicare Program Integrity Manual, Pub. No. 100-08 (Rev. 636, 02-04-16),    
ch. 15,  19.2.2.B. 
14 Two questions on the general site visit form are applicable only to DMEPOS suppliers. 
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  4 
   
 
Fingerprinting.  The ACA also gave CMS the authority to conduct 
fingerprinting for national background checks and criminal history record 
checks.15  According to CMS, fingerprinting would be reserved for owners of 
providers in the high-risk category.  Although fingerprint-based background 
checks were included in the 2011 regulation establishing the enhanced 
enrollment screening procedures, CMS did not award a contract to manage 
this process until 2014, when it selected Accurate Biometrics, Inc. to serve as 
the Fingerprint-Based Background Check Contractor.   
Revalidation.  Prior to the ACA, CMS required DMEPOS suppliers to revalidate 
their enrollment every 3 years, and other providers were required to revalidate 
every 5 years.  The ACA provided CMS with the authority to conduct 
off-cycle revalidations and revalidate the enrollment of all existing providers 
under the new ACA screening requirements.16  This off-cycle revalidation effort 
applies to providers who were enrolled prior to March 25, 2011.  CMS began 
the revalidation process in September 2011.   
APS system.  In 2011 CMS contracted with Turning Point Solutions to 
develop the APS system.  The APS system verifies certain application 
information against government records and private vendor data.  When 
information does not match or criteria are unmetfor example, if the 
providers license has expiredthe APS system will flag that application 
information for MACs and NSC to verify. 
Overpayment screening.  In 2008 CMS modified regulations to allow 
MACs and the NSC to deny enrollment applications if a physician, 
nonphysician practitioner, or a providers current owner has an unresolved       
overpayment. 17, 18  In August 2013 CMS issued guidance to MACs and the 
NSC on denying enrollment applications for providers with unresolved 
overpayments.19  After this guidance was issued, CMS placed the 
implementation of the guidance on hold.  In December 2014 CMS issued a 
final rule, effective February 3, 2015, that clarifies when a provider can be 
 
15 ACA  6401(a), codified at 42 USC  1395cc(j)(2)(B)(ii)(II). 
16 ACA  6401(a), codified at 42 USC  1395cc(j)(2). 
17 73 Fed. Reg. 69726, 69940 (Nov. 19, 2008). 
18 42 CFR  424.530(a)(6). 
19 CMS, Transmittal 479, Change Request 8039, CMS Manual System, Pub. No. 100-08, 
Enrollment Denials When an Existing or Delinquent Overpayment Exists (Aug. 1, 
2013). 
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  5 
   
 
denied enrollment due to unresolved Medicare debts (including 
overpayments). 20  
METHODOLOGY 
Data Collection and Analysis 
CMS data.  We met with CMS staff and collected data regarding enrollment 
and revalidation applications received and processed by MACs and the NSC 
1 year before the implementation of enhanced screening procedures (i.e., 
March 25, 2010, through March 24, 2011) and 1 year after the 
implementation of enhanced screening procedures (i.e., March 25, 2012, 
through March 24, 2013).21, 22  Our analysis compared trends in application 
outcomes across years.     
MAC and NSC procedure data.  From the NSC and the 12 MAC 
jurisdictions that process applications, we obtained and reviewed written 
policies and survey responses regarding enrollment and revalidation 
procedures.  We requested additional information from one MAC regarding 
its review of site visit results and associated application determinations for 
certain providers it enrolled or revalidated.  We also interviewed staff at one 
MAC to learn more about their procedures for processing enrollment and 
revalidation applications.        
NSVC procedure data.  From NSVC we obtained and reviewed written 
policies, training materials, and interview responses regarding site visit 
procedures.  To collect information about site visit inspectors experiences in 
conducting site visits, we surveyed a simple random sample of 200 of the 
866 NSVC inspectors authorized to perform site visits as of 
September 2013.23  We received and reviewed completed surveys from 133 
inspectors.  Because of a survey response rate of 67 percent, we did not 
project the survey responses of the 133 inspectors to the entire population of 
866 inspectors.  
 
20 79 Fed. Reg. 72499 (Dec. 5, 2014).  CMS amended the regulation to allow MACs and 
NSC to deny enrollment applications for any unresolved debt, be it an overpayment or 
some other type of financial obligation to Medicare.  The final rule allows for the denial of 
enrollment if the provider or owner has an unresolved debt or had debt when the 
providers enrollment was terminated or revoked and (1) the owner left the provider that 
had the debt 1 year before or after the providers termination or revocation, (2) the debt 
has not been fully repaid, and (3) CMS determines that the debt poses an undue risk of 
fraud, waste, or abuse. 
21 The time period March 25, 2010, through March 24, 2011, is hereinafter referred to as 
the preimplementation period.  The time period March 25, 2012, through March 24, 
2013, is hereinafter referred to as the postimplementation period. 
22 We did not collect data regarding CMS-855O enrollment applications because this type 
of application did not exist during the preimplementation time period. 
23 We did not include NSVC inspectors located in U.S. territories in our review.  
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  6 
   
 
NSVC site visit results data.  We obtained from CMS detailed results of 
16,022 site visits conducted by NSVC during the postimplementaiton period 
for applications received and processed by MACs within that period.  Of 
these, 1,914 site visits were conducted for IDTFs and 14,108 were 
conducted for non-IDTF providers.  Our analysis compared the results of 
each site visit to the enrollment decision with a date that directly followed 
the date of the site visit.   
APS procedure data.  From the APS contractor, we obtained and reviewed 
written policies and interview responses regarding the APS system.    
Limitations 
We were not able to review the procedures or address the impact of the 
Fingerprint-Based Background Check Contractor because it was not 
operational when we conducted this study.  We did not validate the data 
that CMS provided from its data systems.    
Standards 
This study was conducted in accordance with the Quality Standards for 
Inspection and Evaluation issued by the Council of the Inspectors General 
on Integrity and Efficiency.   
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  7 
   
 
FINDINGS 
Providers submitted fewer enrollment applications 
after CMS implemented risk-screening and site visit 
enhancements 
In March 2011 CMS began assigning providers to risk-screening categories 
and conducting site visits for those in the moderate- and high-risk 
categories.  Providers submitted fewer enrollment applications in the year 
after CMS had implemented these enhancements.  During the 
preimplementation period, providers submitted 546,916 enrollment 
applications, as shown in Table 1.  In the year after implementation of 
enhancements, providers submitted 12 percent (67,801) fewer enrollment 
applications.  This reduction may be evidence of a deterrent effect 
resulting from the enhanced enrollment screening process.   
It was not possible to determine conclusively whether the new 
Medicare enrollment enhancements prevented a greater 
percentage of ineligible providers from entering the program  
CMSs approval of submitted enrollment applications decreased slightly 
from 91 percent to 88 percentafter implementation of the new 
enhancements.  At the same time, CMSs denial of enrollment applications 
decreased, from 2.5 percent to less than 1 percent.  Table 1 provides the 
numbers of approved and denied enrollment applications made before and 
after the implementation of enhanced enrollment screening procedures. 
One might expect an inverse relationship to exist between approval and 
denial percentagesif approval rates decrease, denial rates increase.  But 
this is not the case when one factors in the incomplete applications that 
were returned to providers.  The percentage of applications returned to 
providers because of incomplete information increased from 6 percent to 11 
percent.  Thus, a smaller overall percentage of submitted applications were 
deemed ready for enrollment determinations in the postimplementation 
period. 
 
 
 
 
 
 
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  8 
   
 
Table 1:  Enrollment Results Before and After the Implementation of New Enhancements 
Preimplementation Period  Postimplementation Period 
  (March 25, 2010, through  (March 25, 2012, through 
March 24, 2011)  March 24, 2013) 
Number of Enrollment Applications 
546,916  479,115 
Submitted 
Number Approved   500,076  423,355 
 
Percentage Approved  91.4%    88.4% 
Number Denied   13,600  3,411 
 
Percentage Denied   2.5%   0.7% 
Number Returned   32,857  51,819 
 
Percentage Returned   6.0%  10.8% 
Number Withdrawn   383  530 
 
Percentage Withdrawn  0.1%    0.1% 
Source:  OIG analysis of data compiled by CMS from PECOS, MACs, and the NSC, 2014. 
When we considered only those applications for which enrollment 
determinations were made, the approval rate increased from 97 percent to 
99 percent.  For the applications with determinations, the percentage of 
denials decreased from 2.6 percent to 0.8 percent, as shown in Table 2.  The 
latter denial rate is similar to the 0.7 denial percentage seen across all 
enrollment applications submitted during the postimplementation period.  
Table 2:  Medicare Provider Enrollment Determination Results Before and After the 
Implementation of New Enhancements 
Preimplmentation Period  Postimplementation Period 
  (March 25, 2010, through  (March 25, 2012, through 
March 24, 2011)  March 24, 2013) 
Number of Enrollment Applications 
546,916  479,115 
Submitted 
Number of Enrollment Applications with 
Determinations  513,676  426,766 
     
Percentage of Enrollment Applications  93.9%  89.1% 
with Determinations 
Number Approved   500,076  423,355 
 
Percentage Approved   97.4%  99.2% 
Number Denied   13,600  3,411 
 
Percentage Denied  2.6%  0.8% 
Source:  OIG analysis of data compiled by CMS from PECOS, MACs, and the NSC, 2014. 
Given the multiple types of variation across the two time periodsfewer 
applications submitted, a greater rate of applications returned, a higher rate 
of approvals (and lower rate of denials) among applications with 
determinations in the postimplementation periodit is not possible to 
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  9 
   
 
determine whether the new Medicare enrollment enhancements prevented a 
greater percentage of ineligible providers from entering Medicare.   
CMSs effort to revalidate all existing enrollments 
yielded substantial revocations and deactivations 
The ACA established a requirement for all providers to revalidate their 
enrollment information under the new enrollment screening enhancements.  
This off-cycle revalidation effort applies to all providers enrolled prior to 
March 25, 2011.  All revalidation notices were mailed to providers by 
March 23, 2015.   
During the revalidation process, a providers enrollment can be approved, 
revoked, or deactivated.  Providers who are revalidating their enrollment 
may have it revoked for a number of reasons, including noncompliance 
with Medicare standards.  Providers enrollment can be deactivated when 
they do not respond timely to a revalidation request.    
As outlined in Table 3, the number of revocations and deactivations of 
submitted revalidation applications substantially increased after CMS 
implemented the revalidation effort using risk category and site visit 
enhancements.  However, 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.   
Table 3:  Medicare Provider Revalidation Determinations Before and After 
Implementation of CMSs Revalidation Effort and New Enhancements 
Number of   Number of  Number of  Number of 
  Revalidation  Approvals/  Revocations/  Deactivations/ 
Determinations  Approval Rate  Revocation Rate  Deactivation Rate 
Preimplementation Period 
(March 25, 2010, through March 24, 2011) 
Total  51,673  51,574  62  37 
    99.8%  0.1%  0.1% 
    NSC:  Moderate- and  289  285  0  4 
High-Risk Providers    98.6%  0%  1.4% 
   MACs:  Moderate- and  1,849  1,841  4  4 
High-Risk Providers     99.6%  0.2%  0.2% 
   MACs:  Limited-Risk    49,535  49,448  58  29 
Providers    99.8%  0.1%  0.1% 
Postimplementation Period 
(March 25, 2012, through March 24, 2013) 
Total  177,932  145,234   5,414  27,284 
    81.6%  3.0%  15.3% 
   NSC:  Moderate- and  15,589  15,221  52  316 
High-Risk Providers    97.6%  0.3%  2.0% 
   MACs:  Moderate- and  13,775  11,509  51  2,215 
High-Risk Providers    83.5%  0.4%  16.1% 
   MACs:  Limited-Risk  148,568  118,504  5,311  24,753 
Providers    79.8%  3.6%  16.7% 
.   
Source:  OIG analysis of data compiled by CMS from PECOS, MACs, and the NSC, 2014
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  10 
   
 
Key provider information is not verified during the 
enrollment or revalidation processes 
Providers seeking to enroll or revalidate their enrollment in Medicare must 
submit important application information to CMS.  However, key 
informationi.e., identification numbers, supporting documents, and 
criminal convictionsis not always verified by MACs and the NSC as 
required by CMS policy.  Even when the APS system is fully implemented, 
some key enrollment information will not be verified.24  These gaps in 
CMSs verification of information submitted by providers on enrollment 
applications leave Medicare vulnerable to providers that submit false 
information.     
CMSs contractors did not verify key enrollment information  
CMS has relied on MACs and NSC to verify whether information on 
enrollment and revalidation applications is correct.  Although the Medicare 
Program Integrity Manual directs MACs and the NSC to verify all 
application information, none reported doing so.25, 26  Even when 
contractors did verify key information, they did not always use an outside 
source to do so.27   
Identification numbers.  Providers must submitdepending on the provider 
typeSocial Security numbers, National Provider Identifiers (NPIs), Drug 
Enforcement Agency (DEA) numbers, Tax Identification Numbers (TINs), 
and/or Employer Identification Numbers (EINs) on the application forms 
that MACs process.  None of the MACs reported verifying all the 
identification numbers that providers supply on their individual enrollment 
and revalidation applications.  Nor did the NSC always verify DMEPOS 
suppliers tax identification numbers or EINs with an outside source.   
 
24 CMS began piloting APS system procedures with a subset of MACs in April 2013, but 
as of December 2015, CMS had not used the APS system to routinely screen applications. 
25 Section 15.1.3 of the Medicare Program Integrity Manual states:  Unless stated 
otherwise in this chapter or in another CMS directive, verify and validate all information 
collected on the enrollment application. 
26 Section 15.7.3.B of the Medicare Program Integrity Manual states:  Once the 
contractor has completed its review of the CMS-855 (e.g., approved/denied application, 
approved change request), it shall provide a written statement asserting that it has (1) 
verified all data elements on the application, and (2) reviewed all applicable names on the 
CMS-855 against the MED [Medicare Exclusion Database] and the System for Access 
Management (SAM). 
27 We define an outside source as any source that is external to CMS.  We did not 
consider MACs and the NSCs internal review of provider-submitted documents to 
constitute verification with an outside source.  For certain types of provider information, 
CMS policy does not require verification with what OIG considers an outside source. 
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  11 
   
 
Appendix B outlines the number of contractors that verified identification 
numbers. 
Supporting documentation.  Applicants must submit certain documentation 
with their applications, including copies of licenses, certifications, and 
registrations required by States for certain health care providers; Internal 
Revenue Service documentation; lease agreements; educational degrees; 
and bank statements.  Only the license, certification, and registration 
documentation is verified with an outside source by all MACs and the 
NSC.28 
Criminal convictions.  Applicants must report information regarding final 
adverse legal actions, such as convictions and exclusions from participation 
in Federal health care programs.  All contractors used OIG or General 
Services Administration (GSA) data to verify whether applicants omitted 
exclusions.  The majority of MACs stated that they also use OIG or GSA 
datain addition to State licensure Web sitesto verify whether applicants 
omitted any criminal convictions.  However, these outside sources are not 
comprehensive sources of criminal conviction information.  In addition, the 
NSC does not verify whether applicants omitted information on criminal 
convictions.   
APS will not verify some key application information even after 
the system is fully implemented  
APS will not fully address enrollment vulnerabilities because some key 
application information will still not be verified even after the system is 
fully implemented.  This information includes:  
  TINs of individuals and organizations who have 
ownership/managing control of the applicant;   
  TINs or EINs of other individual or organizational principals 
associated with the applicant, such as an applicants billing agency 
or supervising physician;  
  DEA numbers of applicants; and 
  supporting documentation. 
Contractors were inconsistent in applying site visit 
procedures and using site visit results for enrollment 
decisions  
After the enhancements to the enrollment screening process were 
introduced, less than 2 percent of the 16,022 site visits conducted by the 
 
28 Three of these MACs verify against an outside source only for Part B providers. 
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  12 
   
 
NSVC resulted in denials or revocations of providers enrollment.  For 
another 2 percent of site visits, MACs approved providers for enrollment 
even though site visit results indicated noncompliance with each of CMSs 
standards.   
We found some examples in which NSVC inspectors observational 
comments on the site visit forms contradicted their answers to questions on 
the forms.  In addition, there were inconsistencies in how NSVC inspectors 
determined whether a facility was operational.  Vulnerabilities related to 
the implementation of site visits can compromise the effectiveness of 
screening providers for entry into Medicare.    
MACs approved hundreds of providers to enroll in Medicare 
despite site visit results indicating noncompliance  
MACs approved 362 of the 651 provider enrollment and revalidation 
applications for which NSVC inspectors reported that the providers 
facility did not meet any of the enrollment standards on the site visit form.29  
If these providers had not been approved, there would have been more than 
twice as many denials and revocations from site visits during the 
postimplementation period.   
For these 362 site visits, some NSVC inspectors provided additional 
comments, such as facility does not exist, building has been vacated, 
suite appeared closed and abandoned, calling the telephone number 
resulted in response that the line was disconnected with no forwarding 
number, and facility is closed with a padlock on the door.    
These comments and the inconsistencies between site visit results and 
enrollment determinations 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.  We followed up with one MAC to determine under what 
circumstances it would approve enrollment applications with unfavorable 
site visit results.  Of the nine cases we sent to the MAC for review, the 
MAC reported that in six cases it had not reviewed the site visit results, in 
two cases it had not thoroughly reviewed the site visit results or should 
have conducted more research on the facility location, and in one case it 
may have provided an incorrect location for the site visit.  The MAC 
reported that it had recognized the need to change its standard operating 
procedures.  To ensure that providers are meeting enrollment requirements, 
the MAC now routes certain types of provider applications to a designated 
group of analysts for review. 
 
29 We provided CMS the site visit information for these 362 providers.  
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  13 
   
 
NSVC inspectors observational comments about a facility 
sometimes contradicted their responses to questions on the 
site visit form 
NSVC inspectors can enter additional observations and comments about 
the facility at the end of the general site visit form.  We found several 
examples of site visit results for which NSVC inspectors comments 
contradicted their responses to closed-ended (Yes/No) questions.  For 
example, an inspector answered Yes to indicate that a facility was open, 
yet the inspectors additional comments indicated that the facility was 
closed.  In other cases, inspectors answered Yes to a question about 
whether customers were seen at the facility, yet the inspectors additional 
comments indicated that they saw no customers.  MACs approved the 
enrolling and revalidating providers associated with these instances.  Such 
discrepancies raise questions about (1) potential issues with NSVC 
oversight of quality assurance or training of its inspectors and (2) whether 
MACs are reviewing inspectors additional comments when making 
enrollment and revalidation decisions.30   
NSVC inspectors were not consistent in how they determined 
whether a facility was operational  
One of the questions on the general site visit form asks NSVC inspectors, 
Does the facility appear to be operational?  This is an important criterion 
that site visits are meant to determine.  The form clarifies:    
Operational means the provider or supplier has a qualified physical 
practice location, is open to the public for the purpose of providing health 
care related services, is prepared to submit valid Medicare claims, and is 
properly staffed, equipped, and stocked (as applicable, based on the type 
of facility or organization, provider or supplier specialty, or the services 
or items being rendered) to furnish these items or services.31, 32 
One of the roles of an NSVC inspector is to determine whether a facility is 
operational.  However, 50 of the 133 inspectors that responded to our 
survey reported that they did not receive training regarding how to 
determine whether a facility is operational.  The difficulties surrounding the 
determination of a facilitys operational status may be due to the definition 
of operational, as stated above, which does not provide sufficient detail 
 
30 According to NSVC staff, the results of all site visits are reviewed by a member of the 
NSVC review team before being submitted to CMS.   
31 CMS, Site Verification Survey Form. 
32 NSVC training materials instruct inspectors to disregard the reference to valid 
Medicare claims.  In addition, according to NSVC staff, CMS allows inspectors to 
disregard the parts of the definition referring to being prepared to submit valid Medicare 
claims and being properly stocked because they relate to DMEPOS facilities and not the 
type of facilities that NSVC inspectors visit. 
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  14 
   
 
for inspectors to follow when determining whether the facility is 
operational.  For example, some surveyed inspectors reported finding it 
particularly challenging to determine whether ambulance companies and 
providers that can be located in private residences, such as HHAs, were 
operational because these facilities may not be continuously staffed during 
normal business hours.  
Approximately half of responding inspectors reported that they determine 
whether a facility appears operational solely on how they answered other 
questions on the general site visit form.  The remaining inspectors reported 
that they do not rely solely on how they answered other questions.  When 
we asked inspectors how they determine whether a facility is operational, 
their responses varied.  Methods included, but were not limited to, 
  assessing the condition of the facilitys building,  
  calling the facilitys telephone number, and 
  observing other criteria such as whether or not lights were on, the 
facility had office furniture and supplies, the door was unlocked, 
and equipment was present.   
CMS relies on an enrollment data system, PECOS, that 
does not contain all the information needed for 
effective oversight  
CMS relies on PECOS as its centralized repository for all provider 
enrollment information.  However, PECOS data related to oversight of 
enrollment screening enhancements were often incomplete and therefore 
could not be used to evaluate the impact of certain enhancements 
implemented by CMS.  
PECOS lacked key data to evaluate the outcomes of the new 
enhancements 
Data pertinent to tracking provider enrollment trends associated with the 
recent screening enhancements were not consistently maintained in 
PECOS.  These data included 
  denials and returns of enrollment applications; 
  risk category designations (e.g., limited, moderate, or high risk) for 
each enrolling and revalidating provider; and  
  reasons providers submitted enrollment applications. 
Denials and returns.  PECOS did not contain information on all denials and 
returns that occurred during the time periods before and after the 
enhancements were implemented.  According to CMS staff, the records for 
some denials and returns reside outside of PECOS in MACs local systems.  
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  15 
   
 
To provide complete counts of denials and returns, CMS requested 
supplementary data from MACs. 
However, after receiving the data from the MACs, CMS was still unable to 
provide us with complete information on denials, returns, and withdrawals 
of enrollment applications by provider type because two MACs were 
unable to provide data by provider type.  Because of this lack of data, we 
were unable to compare trends in enrollment application determinations 
across provider types.  This prohibited us from evaluating the impact of 
enhanced screening on the enrollment of higher risk providers.  This lack of 
data also limits CMSs ability to evaluate and oversee the effectiveness of 
its enhanced screening procedures.  
Risk category designations.  PECOS did not contain the risk category 
designations for 10 percent of enrolling and revalidating providers 
applications submitted during the postimplementation period.  According to 
CMS staff, PECOS was not updated to include risk category data at the 
time of the risk category enhancements.  In addition, CMS staff 
acknowledged that MACs do not always enter risk category information 
into PECOS.   
Reasons providers submitted enrollment applications.  PECOS did not 
contain the reason for submission, e.g., new enrollment or change of 
information, for 11 percent of the nearly half-million enrollment 
applications (54,903 of 479,115) submitted during the postimplementation 
period.  According to CMS staff, CMS would need to go back to the MACs 
to obtain submission reasons for these applications because the information 
resides outside of PECOS in MACs local systems.  CMS staff indicated 
that to obtain this data, it would have to issue a technical direction letter to 
the MACs and that it would be a significant amount of work to get that 
information.  In addition to the applications for which CMS could not 
provide a submission reason, there were 91,519 enrollment applications for 
which other was the reason for submission in PECOS.   
The lack of complete data regarding submission reasons in PECOS is 
problematic because for some provider categories, the reason for the 
application affects the level of review.  Only higher risk providers that are 
submitting an application for reasons of new enrollment, revalidation, 
addition or change of practice location, certain changes of ownership, or 
reactivation of enrollment are required to have a site visit.  Therefore, 
knowing the reason a provider submitted an enrollment application is 
necessary to know whether the application required a site visit and whether 
all required site visits were performed.   
 
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  16 
   
 
CMS cannot readily use PECOS to link enrollment outcomes to 
site visit results   
According to CMS staff, the data housed in PECOS cannot be easily used 
to connect the results from site visits to MACs enrollment decisions.  To 
determine a direct link between a site visit result and the enrollment 
decision associated with that specific site visit would require a 
labor-intensive manual review on the part of CMS and its contractors.  In 
this respect, CMSs current enrollment data system presents challenges for 
overseeing implementation of the enhancements to the site visit component 
of the screening process. 
In addition, there was a discrepancy between the number of site visits that 
CMS reported the NSVC as having conducted (17,024 site visits in 
PECOS) and the number of site visits for which CMS provided complete 
and valid results from NSVC (16,022 site visits obtained from the NSVC).  
According to CMS staff, the difference in numbers can be attributed to 
errors in how site visits are tracked in PECOS, possible typographical 
errors, or other data anomalies. 
PECOS may not contain accurate enrollment data on DMEPOS 
suppliers for the preimplementation period   
Prior to October 2010 the NSC stored DMEPOS suppliers enrollment 
information in the Provider Information Management System (PIMS).  In 
October 2010 the NSC converted this information from PIMS to PECOS.  
According to CMS staff, some errors may have occurred during this 
transfer.  To provide data for the year before implementation of 
enhancements, CMS combined data from PECOS and PIMS and stated that 
the data may contain an error rate of at least 10 percent.    
 
   
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  17 
   
 
CONCLUSION AND RECOMMENDATIONS 
OIG has performed extensive work focusing on provider enrollment and 
found significant vulnerabilities in this area and made recommendations for 
improvement.  CMS has implemented new provider-screening tools that are 
intended to reduce vulnerabilities in the provider enrollment process and 
thus reduce the number of illegitimate providers enrolling in Medicare.  
Discouraging illegitimate providers from seeking to gain entry into 
Medicare may have contributed to the decline of enrollment applications 
after the implementation of the enhancements.  
It is not possible to determine conclusively from the results of enrollment 
decisions whether or not the new enhancements to the Medicare enrollment 
process prevented a greater percentage of ineligible providers from entering 
the program.  However, CMSs efforts to revalidate all existing enrollments 
yielded substantial revocations and deactivations of providers billing 
privileges.  As a result of its revalidation and screening efforts, CMS 
reported that 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.   
However, the gaps in CMSs verification of information submitted by 
providers on enrollment applications leaves Medicare vulnerable to 
providers that submit false information.  Additionally, CMS should 
improve the implementation of enhancements such as site visits to ensure 
that providers are being effectively screened for entry into Medicare.   
Effective oversight of enrollment data is key to ensuring that contractors 
are performing their activities appropriately and that enhancements are 
producing intended results.  At the time of our review, shortcomings in 
PECOS rendered CMS unable to leverage existing data to determine how 
the enhancements were affecting provider enrollment.   
Preventing dishonest providers from enrolling in Medicare is the first step 
in ensuring the integrity of the program.  Therefore, to strengthen the 
provider enrollment-screening process, we recommend that CMS:  
Monitor MACs and the NSC to determine whether they are 
verifying information on enrollment and revalidation 
applications as required    
According to the Medicare Program Integrity Manual, contractors must, 
unless otherwise specified, verify and validate all information collected on 
the enrollment application.  CMS should confirm that all the information 
on an enrollment or revalidation application is verified as required.  
Verifying this information is an important safeguard to prevent 
unscrupulous providers from enrolling in Medicare. 
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  18 
   
 
Validate that MACs are appropriately considering site visit 
results when making enrollment decisions 
Site visits are used to determine whether providers actually exist at the 
physical locations on file with CMS.  As a means to reduce inappropriate 
Medicare payments, OIG has recommended and supported the use of site 
visits to deny enrollment to providers who do not maintain operational 
facilities.  However, this tool is rendered ineffective if MACs approve 
enrollment and revalidation applications when site visits show that 
providers are failing to meet CMSs standards.  CMS should determine 
why these approvals occur and address any identified problems with its 
contractors.  CMS should also instruct MACs to review their standard 
operating procedures to ensure they are reviewing and appropriately using 
the results of site visits for enrollment decisions. 
Revise and clarify site visit forms so that they can be more 
easily used by inspectors to determine whether a facility is 
operational  
The general site visit form is used by inspectors to indicate whether or not a 
facility is operational and, in turn, by MACs to determine whether the 
provider meets the operational criteria for enrollment.  CMS should issue 
more specific guidance to the NSVC as to what it means for a facility to be 
considered operational.  This includes guidance as to what CMS expects 
inspectors to observe during a site visit for them to consider a facility 
operational.  In addition, CMS may consider whether customized site 
visit forms for certain provider types or more in-depth questions on the 
general site visit form are needed to minimize confusion and 
inconsistencies. 
Require the NSVC to improve quality assurance oversight and 
training of site visit inspectors  
Although the NSVC has quality assurance processes and trains its site visit 
inspectors, we identified instances in which inspectors reported 
contradictory information in their site visit results and inconsistencies in 
how inspectors determined whether a facility appeared operational.  To 
ensure that NSVC inspectors provide the MACs with consistent and valid 
site visit assessments, CMS should require that the NSVC improve its 
quality assurance oversight of inspectors and provide more specific training 
to inspectors as to how to determine whether a site is operational.   
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  19 
   
 
Ensure that PECOS contains the complete and accurate data 
needed to execute and evaluate CMSs enrollment-screening 
enhancements 
PECOS is CMSs national data repository for Medicare enrollment 
information about providers.  The information housed in PECOS can aid 
CMS in tracking enrollment and revalidation trends as well as determine 
whether contractors are abiding by program requirements.  For CMS to 
accomplish this, however, the data maintained in PECOS must be complete 
and accurate.  CMS should ensure that PECOS includes fields that relate to 
the enhancements implemented for the provider enrollment process and 
that MACs and the NSC enter all required data.   
   
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  20 
   
 
AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 
RESPONSE 
CMS concurred with all five of our recommendations.  In its comments, 
CMS highlighted its most recent efforts as it continues to improve upon the 
new enrollment enhancements.  For example, CMS notes that it is 
expanding the use of site visits and has made improvements to the NSVC 
training process since the time of our review.  CMS also described the ways 
in which it has already made progress on our recommendations.  Some of 
this progress includes working with the MACs and NSC to ensure they are 
verifying all information on enrollment and revalidation applications, 
analyzing data provided by OIG on site visit results that were inconsistent 
with enrollment decisions, revising the general site visit form, and 
improving the accuracy and completeness of data stored in PECOS.  We 
look forward to receiving updates from CMS on its progress toward these 
recommendations through the actions it described.  Appendix C contains 
the full text of CMSs comments. 
   
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  21 
   
 
APPENDIX A 
Figure A-1:  General Site Visit Form 
   
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  22 
   
 
APPENDIX B 
Table B-1 provides information on whether the 12 MACs and the NSC reported verifying 
the identification numbers that providers submitted on enrollment and revalidation 
applications.  In addition, Table B-1 shows the number of contractors that verified these 
identification numbers using a source external to CMS.  We did not consider MACs and 
the NSCs internal review of provider-submitted documents to constitute verification with 
an outside source.   
 
Table B-1:  Number of Contractors That Verify Identification Numbers Submitted 
by Providers on Enrollment and Revalidation Applications 
MACs  NSC 
Number  Verifies 
Type of  That  With 
Application  Number  Verifies 
Identification  Entity  Verify  Outside 
Form(s)  That 
Number  With  Source1 
Verify 
Outside 
Yes = 1, No = 0 
Source1 
Individual with ownership/managing control  11  11  1  1 
All CMS-855 
forms 
Billing agent  7  7  0  0 
CMS-855S  Sole proprietor  N/A  N/A  1  1 
Social  CMS-855I  All applicants  11  11  N/A  N/A 
Security 
Number  CMS-855A  Chain home office administrator  6  6  N/A  N/A 
IDTF supervising physician   11  11  N/A  N/A 
CMS-855B  IDTF interpreting physician   11  11  N/A  N/A 
IDTF technician  11  11  N/A  N/A 
All CMS-855  Each practice location, business, and/or 
9  7  1  1 
forms  group affiliation of all applicants 
CMS-855S  Billing agent/agency  N/A  N/A  0  0 
Physician assistants employer when 
11  11  N/A  N/A 
establishing employment   
Physician assistants employer when 
CMS-855I  10  10  N/A  N/A 
physician assistant is terminating employment  
Physician assistant when employer is 
9  9  N/A  N/A 
terminating employment  
National  Old owner in changes of ownership   10  9  N/A  N/A 
Provider 
Identifier  Acquiring provider   10  10  N/A  N/A 
CMS-855A  Provider being acquired  9  9  N/A  N/A 
Consolidating provider   7  7  N/A  N/A 
Individual with ownership/managing control   9  9  N/A  N/A 
IDTF supervising physician   11  11  N/A  N/A 
CMS-855B 
IDTF interpreting physician   11  11  N/A  N/A 
CMS-855A, 
Organization with ownership/managing 
CMS-855B,  8  8  0  0 
control 
CMS-855S 
continued on next page 
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  23 
   
 
Table B-1:  Number of Contractors That Verify Identification Numbers Submitted 
by Providers on Enrollment and Revalidation Applications (Continued) 
MACs  NSC 
Number  Verifies 
Type of  That  With 
Application  Number  Verifies 
Identification  Entity  Verify  Outside 
Form(s)  That 
Number  With  Source1 
Verify 
Outside 
Yes = 1, No = 0 
Source1 
National 
CMS-855B, 
Provider 
CMS-855I,  Individual with ownership/managing control  11  11  0  0 
Identifier 
CMS-855S 
(continued) 
Drug 
Enforcement 
CMS-855I  All applicants, if applicable  0  0  N/A  N/A 
Agency 
Number 
All CMS-855 
Billing agent/agency  4  2  0  0 
forms 
Applicant  N/A  N/A  1  0 
Prior tax identification number for business 
N/A  N/A  0  0 
entity 
CMS-855S 
Organization with ownership/managing 
N/A  N/A  0  0 
control 
Tax  Surety bond company  N/A  N/A  0  0 
Identification 
Number  CMS-855I  Business entity  8  0  N/A  N/A 
Chain home office  5  0  N/A  N/A 
CMS-855A  New provider in consolidations   4  0  N/A  N/A 
Nursing registry  4  2  N/A  N/A 
All applicants  5  0  N/A  N/A 
CMS-855A, 
CMS-855B  Organization with ownership/managing 
7  0  N/A  N/A 
control 
Sole proprietor  N/A  N/A  1  0 
CMS-855S 
Prior employer identification number of sole 
N/A  N/A  0  0 
proprietor 
Employer 
Sole proprietor   8  0  N/A  N/A 
Identification 
Number  Physician assistants employer when 
11  0  N/A  N/A 
CMS-855I  establishing employment  
Physician assistants employer when 
10  0  N/A  N/A 
physician assistant is terminating employment  
   
Source:  OIG analysis of data submitted by 12 MACs and the NSC, 2014.
 
1 This is the number of contractors that verify the identification number using information from a source that is external to CMS.  We did not consider 
MACs and the NSCs internal review of provider-submitted documents to constitute verification with an outside source.  For certain types of provider 
information, CMS policy does not require verification with what OIG considers an outside source.   
 
 
   
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  24 
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bbiilllliinngg pprriivviileleggeses ffoorr mmoorree tthhaann 554433,,000000 pprroovviiddeersrs aanndd ssuuppppllieiersrs aass aa rreessuulltt ooff rreevvaalildidataiotinon aanndd 
ootthheerr ssccrreeeenniningg eeffffoor1tsis aanndd mmoorree tthhaann 3344,,000000 pprroovviiddeersrs aanndd ssuupppplileierr eennrroolllmlmenetnsts hhaavvee bbeeeenn 
rreevvookkeedd.. IInn aaddddiittioionn,, CCMMSS hhaass ppeerrffoormnneded nneeaarrllyy 225500,,000000 ssiittee vviissiittss oonn MMeeddiiccaarere pprroovvidideresrs aanndd 
ssuupppplliieersr.s. CCMMSS uusseess ssiittee vviissiittss ttoo vveerriiffyy tthhaatt aa pprroovvidideer'rs's oorr ssuuppppllieier'rs's pprraacctitcicee llooccaattiioonn mmeeeettss 
rreeqquuirieremmenetnsts aanndd hheellppss pprreevveenntt qquueessttioionnabalbele pprroovviiddeersrs aanndd ssuuppppllieiersrs ffrroomm eennrroolllilningg oorr 
mmaaiinntatainininigng eennrroolllmlmenetnt iinn tthhee MMeeddiiccaarere pprrooggrraamm.. AAllll MMeeddiiccaarere pprroovviiddeersrs aanndd ssuupppplileiersrs aallrreeaaddyy 
eennrroollleledd pprriioorr ttoo tthhee nneeww ssccrreeeenniningg rreeqquuiirreemmenetnsts bbeeccoomminingg eeffffeeecttivivee wweerree sseenntt rreevvaalildidataiotinon 
nnoottiicceess bbyy MMaarrcchh 2233., 22001155.. 
CeMMSS iiss aallssoo wwoorrkkiningg ttoo eexxppaanndd iittss uussee ooff ssiittee vviissiittss.. CCMMSS wwiillll bbee iinnccrreeaasisnigng tthhee nnuummbberer ooffssiittee 
vviissiittss tthhaatt iittss ccoonnttrraacctotror ppeerrffoormrms,s, iinniittiiaalllyly ttaarrggeettiningg tthhoossee pprroovvidideersrs aanndd ssuupppplileiersrs tthhaatt rreecceeivivee 
EEnnhhaanncceedd EEnnrroolllmlmeenntt SSccrreeeenniningg ooff MMeeddiiccaarere PPrroovviiddeerrss::  EEaarrllyy IImmpplleemmeenntattaiotinon RReessuultltss ((OOEEIl--0033-1-13-30-00005005)0)  2255 
/S/  
 
   
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  26 
   
 
 
 
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  27 
   
 
ACKNOWLEDGMENTS 
This report was prepared under the direction of Linda Ragone, Regional 
Inspector General for Evaluation and Inspections in the Philadelphia 
regional office. 
Tanaz Dutia served as the team leader for this study.  Other Office of 
Evaluation and Inspections staff from the Philadelphia regional office who 
conducted the study include Robert A. Vito, Joanna Bisgaier, and 
Nancy J. Molyneaux.  Central office staff who provided support include 
Evan Godfrey, Althea Hosein, Joanne Legomsky, Scott Manley, and 
Christine Moritz.  
Enhanced Enrollment Screening of Medicare Providers:  Early Implementation Results (OEI-03-13-00050)  28 
   
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