Healthcare Provider Alert Regarding Medicare Enrollment and Reporting
In my experience, enrollment and credentialing is often viewed by healthcare providers as simply a “clerical” or administrative matter, something that does not require their focused attention. In recent years, however, Centers for Medicare & Medicaid Services (CMS) has stepped up its oversight of enrollment errors and deficiencies and has used these issues to revoke provider billing privileges. The consequences to providers, especially those whose practices are heavily Medicare dependent, can be financially devastating.
A few basics here, just for the sake of context. When healthcare providers initially enroll in the Medicare system, they create an online account and fill out an extensive application form. The online enrollment system is known as the Provider Enrollment, Chain and Ownership System (PECOS). After initial enrollment, providers must periodically revalidate their enrollment to maintain billing privileges (generally every five years but Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers revalidate every three years). Furthermore, and importantly, providers must keep their information current in PECOS and promptly update significant changes, such changes in ownership or practice location, within required timeframes.
CMS has long had the ability to deactivate or revoke a provider’s enrollment for false or misleading information. That enforcement authority has at times been used with little due process in harsh and arbitrary fashion. It is therefore concerning that effective Jan. 1, 2026, CMS has substantially expanded its enforcement authority in this area to allow for even more severe consequences.
The new rules primarily impact the timing of deactivation or revocation. In the past, revocations took effect prospectively, typically 30 days after CMS gave notice of a violation. Now, in some circumstances, CMS can retroactively revoke enrollment back to the date when the alleged violation occurred. If the revocation is upheld, CMS can seek to recoup payment of claims made to the provider with dates of service beginning on the retroactive revocation date. A provider in this situation could be in severe financial peril.
For example, CMS may revoke enrollment based on false or misleading information contained in the initial enrollment application form submitted by the provider to the PECOS system. In this situation, the new rules allow revocation to be retroactive back to the date of initial enrollment, meaning that all of the provider’s billings to the Medicare program over a lengthy time period would be in jeopardy.
In addition, CMS can revoke enrollment if a provider fails to timely report –
· A change in ownership
· An adverse legal action
· A change in practice location
“Timely” typically means as soon as practical, but no later than 30 days.
Providers should note that revocation action does not require intentional misconduct. Even inadvertent errors can result in revocation reaching back for months or years. As a result, prudent providers will not simply delegate enrollment function to third party billing services, untrained or inexperienced staff, or even office managers. The provider’s ability to bill Medicare is at stake here, and the aforementioned persons may not understand (or even care about) the consequences of their errors. I recommend that providers personally review in advance the information to be submitted on their behalf to the PECOS system. This is a key compliance responsibility and carelessness here can be catastrophic to a practice. Here, as elsewhere, ignorance of the rules is not a defense.
Lastly, providers should know that if they are given notice of revocation by CMS, they do have appeal rights, but there are strict time limits for doing so and competent legal counsel is a must.
