The High Cost of Inaccurate Provider Enrollment for Nursing Homes

Posted by Joe Stefansky on April 25, 2023 in CMS, Industry News, Nursing,

As providers of Medicare services, nursing homes rely heavily on the timely and accurate reimbursement from the government to ensure the provision of top-quality care to their residents. The negative financial implications of claim rejections due to inaccurate provider enrollment cannot be overstated, as nursing homes risk losing millions of dollars, leading to their financial instability and, subsequently, their ability to provide quality care.

Beginning April 1st, 2023, a claim with any invalid or inaccurate provider information will be rejected for all services for the entire month. This new regulation further emphasizes the need for nursing homes to prioritize accurate provider enrollment, as even minor errors such as misspelled names or outdated addresses can lead to costly claim denials, which can result in significant revenue losses and cash flow issues.

The consequences of these denials on nursing homes can be far-reaching, as they heavily rely on Medicare reimbursements to maintain their operations and ensure that their residents receive adequate care. Claim rejections can lead to significant financial losses, impairing the nursing homes’ ability to meet financial obligations and purchase necessary supplies.

Moreover, correcting inaccuracies in the enrollment information can be a complex and expensive process that can take up valuable time and resources. This often leads to nursing home staff being pulled away from their core duty of providing care to residents, further exacerbating the situation.

Thus, nursing homes must prioritize accurate provider enrollment by working with experts, such as Streamline Verify, to ensure that their provider information remains up-to-date in the Provider Enrollment, Chain, and Ownership System (PECOS). Through this, nursing homes can avoid costly claim rejections and concentrate on providing the best possible care to their residents.

Furthermore, it is important to note that effective April 1, 2023, Medicare systems will edit institutional claims to ensure that institutional providers do not use any organizational National Provider Identifier (NPI) in the Attending Provider NPI Data Element, except under specific exceptions. Institutional providers must indicate the Attending Provider Name and Identifiers for the patient’s medical care and treatment on institutional claims for any services other than nonscheduled transportation claims. Additionally, on outpatient claims, institutional providers must send the Referring Provider NPI and name when the Referring Provider for the services is different from the Attending Provider.

It is crucial for healthcare compliance officers to stay informed of these new regulations and work with their team to ensure that their organization is compliant. Failure to do so can lead to significant revenue losses, cash flow issues, and difficulty in providing quality care to patients.

About Joe Stefansky

About Joe Stefansky

Joe Stefansky has a keen sense of business opportunities in complex problems, using technology to transform difficulty into efficiency. The CEO and founder of Streamline Verify specializes in solving compliance, legal and administrative issues through intuitively designed software that reduces costs and saves time.

Related Articles

Unprecedented Surge in OIG Exclusion List: ...

November 9, 2023

The Office of Inspector General (OIG) today updated the LEIE Downloadable List – an addition of a staggering 403 new names to the Exclusion List. This marks the highest number of new entries for the...

The Baby-Boomer Effect: How Healthcare Fraud ...

January 18, 2016

  The National Healthcare Anti-Fraud Association approximates 3 to 10 percent of annual healthcare expenditures account to fraudulent claims. This means that in the $600 billion spent for Medica...

Driving Healthcare Costs Down, By Bringing ...

January 4, 2016

  Why does medical care cost so much, anyway? Dumb question.  It doesn’t take a rocket scientist to understand that healthcare costs.  Treatments cost, prescriptions cost, equipment costs. ...

Understanding OIG Exclusions

OIG Exclusions Screening Process

Exclusion FAQS

Quick OIG Exclusion Basics

Employing Excluded Individuals

Consequences to Employing an Excluded Individual

OIG Compliance Law

Laws and Publications on OIG Compliance

More Compliance Resources

Our Culture

We build the best, so you can perform at your best.

Trusted for Good Reason

  • ✓ Guaranteed accurate
  • ✓ Certified Secure
  • ✓ Audit Proof
  • ✓ Feature-rich reporting
  • ✓ Round the clock real-time-data
  • ✓ Processing fully automated

Security First

  • ✓ Cloud hosted
  • ✓ Encrypted data
  • ✓ Real-time backups

Trusted for Accuracy

  • ✓ Physical security
  • ✓ Restricted access
  • ✓ Single sign-on
  • ✓ Password security
  • ✓ Certified secure
  • ✓ Cross checking




Average workload reduction by implementing the Streamline Verify program



Establishments trust Streamline Verify nationwide



Serving the healthcare industry’s unique compliance needs since 2011



Setting standards with hourly synchronization to primary source data