Medicare Revalidation – Why?


Since the first day that CMS announced the revalidation process for Medicare, we’ve been asked the same question time after time.

Why do we have to do this?

Well a simple question begs a not so simple answer. We’ll do our best to provide you answers as we see it from our billing office perspective.


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.) Prior to a few years ago, such a system did not exist. Each Medicare “carrier” as they were called back then, maintained a separate database of providers and there was little ability for cross-checking and verification of information across those carrier lines.

Today, with the advent of the Medicare Jurisdictions across the United States, which amount to groups of States under the now-relabeled Medicare Administrative Contractors (MAC’s); information about a provider 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 reported insolvency, this is one method that the Federal Government in the entity of 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.

Electronic Funds Transfer

As part of the revalidation process, CMS will also force all payment of claims submitted into an electronic process using the efficient Electronic Funds Transfer (EFT) payment system. Unlike in the days of paper checks, your Medicare payments must begin being received electronically as part of this process.

In addition to filing the revalidation application, providers must also complete the appropriate EFT paperwork and begin receiving ACH transfers of Medicare reimbursement dollars direct to a provider- maintained bank account.

This process protects against the possibility of lost and stolen checks arriving via traditional mail.  The EFT process also has a cost-saving effect for the MAC’s  with immediate savings of mailing, paper and printing costs while also moving the system to a more “green” approach.

Are You Revalidating?

Have you received a revalidation request?

If you are a client, by now you should have received an informational e-mail giving you exact instructions on how to provide us with the necessary information and documents so we can prepare the revalidation process on your behalf.

If you are not a client, are you left to complete this complicated application process by yourself or do you have help? If you are outsourcing your billing and your billing contractor is not assisting you, maybe it’s time to look for a new contractor. We’d love to hear from you.

If you’re not outsourcing your billing, but find these new initiatives a bit overwhelming; then maybe it’s time to think about outsourcing. One of the big advantages of outsourcing your ambulance company’s billing is to shed the responsibility of worrying about the many new changes and initiatives faced by ambulance providers on a growing basis.

Why Not Give us a Call?

We’d love to talk with you about your ambulance billing program and how it collides with the compliance mandates of today. Contact us today for more information about the services we provide here!

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