CMS places all provider and supplier types into risk categories—limited,  moderate, or high—based on CMS’s assessments of the potential risk of  fraud, waste, and abuse each provider and supplier type poses to  Medicare program integrity. CMS Applied the Revised Enrollment Screening Process to over 2.4 Million New Applications and Existing Records, and Estimated Avoiding $2.4 Billion in Medicare Payments to Ineligible Providers and Suppliers

		CMS Denied or Rejected over 23,000 New Applications and Deactivated or Revoked over 703,000 Existing Enrollment Records

According to our analysis of PECOS data, CMS applied its revised  enrollment screening process to over 2.4 million unique new applications  and existing enrollment records from March 25, 2011, through December  31, 2015. Many were the result of enrollment screening conducted during  CMS’s first revalidation cycle. CMS Estimates It Avoided $2.4 Billion in Medicare Payments to Ineligible Providers and Suppliers from Enrollment Screening Process, Among Other Benefits

CMS estimates the revised enrollment screening process avoided $2.4  billion in Medicare payments to ineligible providers and suppliers from  March 2011 to May 2015, and CMS and MAC officials report additional  benefits. CMS Modified Elements of the Revised Enrollment Screening Process and Plans to Implement Further Modifications in the Future

Since 2011, CMS has modified some of the methods it uses to screen  providers and suppliers trying to enroll or maintain eligibility to bill  Medicare. CMS  officials stated that they have not yet determined future modifications and  are waiting to see the results of the previous modifications before  modifying the enrollment process further. CMS and MAC officials said they meet periodically to examine  operational efficiency. Despite these efforts, we found that CMS’s monitoring of enrollment  screening, including screening conducted as part of revalidation, lacks  objectives and performance measures for assessing progress toward  achieving its goals. Federal internal  control standards specify that management should define objectives in  specific and measurable terms, establish appropriate performance  measures for the defined objectives, and conduct ongoing monitoring so  that progress toward achieving desired goals can be assessed. CMS officials  stated that while they want to assess the screening process, they are  uncertain of what performance measures to establish in part because  they are concerned that some measures would be inappropriate. However, without developing objectives and performance measures to  use in ongoing monitoring, the agency will be unable to measure the  progress it has made toward achieving its goals for the screening process  and for revalidating provider and supplier enrollment information. While there may be challenges in developing  such objectives and performance measures, there are opportunities to do  so that would allow CMS to better monitor the enrollment screening  process without setting specific targets for the number of deactivations or  revocations. For example, CMS could focus on developing objectives and  performance measures related to its goals for enrollment screening, such  as keeping enrollment information up to date. CMS has  subsequently modified some elements and conducted monitoring of the  process. As CMS considers future  modifications to the enrollment screening process and undertakes its  second program-wide revalidation effort, opportunities exist to address  limitations in its current monitoring of the process. Recommendation for Executive Action

To improve the efficiency and effectiveness of the agency’s enrollment  screening process, we recommend that the Administrator of CMS  establish objectives and performance measures for assessing progress  toward achieving its goals. In commenting on this report, HHS agreed with our recommendation. Appendix II: Examples of Operational Modifications to Revalidation

The Centers for Medicare & Medicaid Services (CMS) has made  operational modifications to revalidation since 2011.
Why GAO Did This Study

An effective provider and supplier enrollment process is a cornerstone of ensuring Medicare program integrity and limiting improper payments. The Patient Protection and Affordable Care Act contained provisions designed to strengthen CMS's enrollment screening process. In response, CMS implemented a revised screening process on March 25, 2011, that assigned all providers and suppliers to one of three risk categories—limited, moderate, or high—and based screening on the level of potential risk of fraud, waste, and abuse they present. The process is used to screen prospective, and revalidate enrolled, providers and suppliers. In September 2011, CMS began its first large scale revalidation effort to verify all enrolled providers' and suppliers' information and determine whether they remain eligible to bill Medicare. As of March 2016, it had begun its second large scale revalidation effort.
GAO was asked to examine the revised enrollment screening process. GAO examined 1) the results of the 2011 revised screening process, 2) CMS's implemented or planned modifications to the process, and 3) CMS's monitoring of the revised process. GAO examined enrollment data from March 25, 2011, through December 31, 2015, reviewed CMS policies and procedures, and interviewed CMS and Medicare contractor officials.

What GAO Found

GAO's analysis of the Centers for Medicare & Medicaid Services' (CMS) Medicare enrollment data found that CMS used its revised enrollment screening process to screen and revalidate over 2.4 million unique new applications and existing enrollment records. GAO's analysis showed that the screening resulted in over 23,000 new applications being denied or rejected and over 703,000 existing enrollment records being deactivated or revoked. CMS estimates the revised process avoided $2.4 billion in Medicare payments to ineligible providers and suppliers from March 2011 to May 2015 and resulted in other benefits, such as more accurate provider and supplier enrollment data. In June 2015, GAO reported some inaccuracies in the enrollment data after the revised process took effect, such as potentially ineligible practice location addresses, which CMS has taken action to address.
Since 2011, CMS has implemented some modifications to the revised screening process and made operational modifications to its revalidation efforts. For example, CMS eliminated automatic approvals of provider and supplier requests to extend the deadline for submitting enrollment information for revalidation. CMS officials stated that they plan to implement further modifications, but have not yet identified these future modifications. CMS officials said that they are waiting to see the results of the previous modifications before modifying the enrollment process further.
CMS has set goals and conducted monitoring of the enrollment screening process, but those monitoring activities lack objectives and performance measures for assessing progress toward those goals. CMS officials said they want to assess the screening process but they are uncertain of what objectives and performance measures to establish, in part because they are concerned that some measures would be inappropriate. While there may be challenges in developing objectives and performance measures, there are opportunities to do so that would allow CMS to better monitor the enrollment screening process without setting specific targets that could create inappropriate incentives for contractors. For example, CMS could focus on developing objectives and performance measures related to its goals for enrollment screening, such as keeping enrollment information up to date. Federal internal control standards and leading practices specify defining objectives and establishing performance measures so that an agency can monitor progress toward achieving desired goals. Without objectives and performance measures to use in ongoing monitoring, CMS will be unable to measure the progress it has made toward achieving its goals.
In commenting on this report, the Department of Health and Human Services agreed with GAO's recommendation.

What GAO Recommends

To improve the revised screening process, CMS should establish objectives and performance measures for assessing progress toward achieving its goals.