Why Medicare revalidation is critical to maintaining eligibility and avoiding penalties

Medicare is the largest payer for most practitioners, so it’s important that providers maintain current credentials. Medicare requires providers to revalidate every five years to verify credentials and ensure they meet Medicare qualifications. Providers must confirm or update information including the legal entity name, physical address, phone, fax, national provider identifiers, employer identification number, and board certifications and licenses if applicable.

While typically a straightforward process, if not completed correctly and on time, providers will be terminated from the program and required to reapply. Until a new application is processed and approved, which can take anywhere from 90-120 days, reimbursements will stop, disrupting the revenue cycle.

Occasionally, providers may receive off-cycle revalidation requests. These are typically triggered when anomalies are identified such as billing rates that are significantly higher than other providers in the same geography, billing for services not rendered or billing patients for services that Medicare doesn’t allow.

To comply with Medicare revalidation requirements, providers need to know their revalidation schedule and make sure applications and supporting documentation are submitted through Medicare’s PECOS online application portal. Revalidation dates cannot be extended, so it’s important they’re submitted on time. Using a third party to navigate the nuances of Medicare revalidation and PECOS removes the burden from provider staff and ensures accurate and timely filing.

TriZetto Provider Solutions (TPS) offers an end-to-end credentialing service that includes continuous payer follow up and insight into enrollment status.  Our dedicated team takes provider data, verifies it for accuracy and submits credentials for revalidation through PECOS. All Medicare-participating providers are subject to revalidation, and mistakes made before or during the process can result in loss of eligibility and other penalties. Having nearly four decades of experience working with payers and providers, we understand the importance of maintaining current credentials. Call us to learn more about our Medicare revalidation services.