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For many health care providers, enrolling in the Medicare and Medicaid programs is considered a one-time activity to allow them to bill that program. Once complete, not much attention is usually paid to the ongoing accuracy of the record. Even when providers revalidate their enrollment (as is required approximately every five years), inaccurate information may remain because the updating process doesn’t request verification of all the information in the provider enrollment record (PER).

What Information Is Included in the PER?

The PER documents contain much more than just the legal business name, individuals or entities who own, control and manage the provider and the bank where electronic payments are to be deposited. Certainly, these are all necessary elements that should be accurate; however, many other data elements are included as well. We frequently see information—such as addresses where service is provided, contacts for the record and names of board members (if applicable)—change without getting updated in the record, even through the revalidation process.

Of particular importance, the name of the authorized official with access to the Provider Enrollment, Chain, and Ownership System (PECOS) and/or the PER itself may change with turnover in key leadership positions. For hospitals and clinics that work with physicians and practitioners, reassignments of benefits may get overlooked, creating payment issues for both the physician and hospital or clinic.

What Are the Updating Requirements?

CMS requires that any change to elements contained in the PER must be reported within 90 days of the change. Frequently, health care providers don’t update the PER because they're either unaware that the change they’ve made requires updating or unfamiliar/confused with the updating process. So far, having outdated PER or PECOS information hasn’t resulted in critical problems for most providers that delay or don’t comply with updating requirements. However, one significant exception to this is when turnover occurs in key positions and the PER isn’t updated. In those circumstances, providers may have billing privileges suspended and lose access to certain notifications, which may contribute to noncompliance.

With increasing emphasis by program integrity contractors at the state and federal levels, health care providers must give more attention to maintaining the accuracy of the enrollment record. Because the process is done infrequently, it can be confusing and difficult to understand. If you have questions about whether changes in your organization necessitate a change in the PER or need assistance with provider enrollment or revalidation, contact Bob or your trusted BKD advisor.

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