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January 5, 2023

7 Steps to Medicare Compliance

Written by: Joni Ogle, LCSW, CSAT

So what does CMS want from you? Learn about the 7 steps to Medicare Compliance

Medicare is federally regulated and requires healthcare providers to ensure that they comply with the many requirements before being eligible for reimbursement.

What does this mean?

Well, this means that healthcare providers need to be diligent about ensuring that regulations for Medicare are followed for all aspects of healthcare delivery - from medical documentation to hospital policies; this article covers the basics of Medicare compliance.

Applying for Medicare compliance can be a daunting task for healthcare providers. The Centers for Medicare and Medicaid Services (CMS) has outlined several steps that providers must take to become and remain compliant with the Medicare program.

In this article, we will provide an overview of the seven steps, as well as tips on how to complete them. Keep in mind that this is not an exhaustive guide, but it will provide you with a good starting point for becoming compliant with Medicare.

Understanding the Basics of Medicare

Medicare is a national health insurance program for Social Security recipients over 65 or permanently disabled. In the United States, the program is administered by the Centers for Medicare and Medicaid Services (CMS).

To provide services to Medicare in Florida beneficiaries, healthcare providers must enroll in Medicare. This includes providers like hospitals and clinics. The process of enrolling in Medicare is known as the Provider Enrollment, Eligibility, and Certification System (PECOS).

Medicare is divided into 4 parts: A, B, C, and D.

  • Part A covers hospitalization, skilled nursing care, and home health care.
  • Part B covers outpatient services which include preventive services.
  • Part C allows beneficiaries to choose a private health plan instead of the original Medicare.
  • Part D covers prescription drugs.

Complying With Medicare Regulations

Healthcare providers need to comply with Medicare regulations. This means knowing your responsibilities as a provider, establishing standards of conduct for Medicare compliance, and establishing a method of oversight. Additionally, all staff should be properly trained on Medicare compliance.

Failure to comply with Medicare regulations can result in serious penalties, including fines and imprisonment. So it's important to take these steps to ensure that your organization complies with the law.

1. Pre-Enrollment Planning for Medicare Compliance

Healthcare providers who want to apply for Medicare compliance should begin by reviewing the revised guidance from CMS. The first step is to enroll in Medicare and to make sure that the HICN (Healthcare Identification Number) is included on all enrollment forms.

A compliance plan must also be established, and this plan should be voluntary in nature. All employees must be trained on the plan, and regular compliance reviews must be conducted. Finally, CMS recommends that regular communication with the Medicare Beneficiary Ombudsman Program be maintained.

2. Developing a Plan for Training Staff on Medicare Compliance

One of the most important steps in ensuring Medicare compliance is to develop a plan for training staff on the requirements. This plan should include who will be responsible for providing the training, how often it will be conducted, and what topics will be covered.

It's important to make sure that all staff members are properly trained on the requirements, as this can help prevent potential problems down the road. Additionally, regular training can help ensure that staff members are up-to-date on any changes to the requirements.

If you're not sure where to start, there are several resources available that can help you develop a training plan. The Centers for Medicare & Medicaid Services (CMS) provides several educational materials on their website, including an overview of the Medicare compliance process. Additionally, several private companies offer compliance training services.

3. Completing Documentation and Submitting 

When completing the documentation for the Medicare application process, all information must be accurate. The Centers for Medicare and Medicaid Services (CMS) will not process an application with missing or incorrect information.

In addition to ensuring accuracy, specific requirements must be met depending on the provider/supplier type. These requirements are available on the CMS website.

When applying to the Marketplace, there may be some cases where additional documentation is requested to verify the information provided on the application. This documentation can include tax forms, birth certificates, or other items depending on the state in which you apply.              

4. Monitoring Compliant Practices

To make sure that your organization is staying compliant, you need to have a process in place to monitor the implementation of compliant practices. This process should include regular check-ins and audits to ensure that policies and procedures are being followed and that compliance risks are being managed effectively.

It's also essential to have a mechanism in place for employees to report any compliance concerns. This could be something as simple as an anonymous hotline or an online form. Having this in place can help prevent compliance issues from happening in the first place.

The Office of Inspector General (OIG) recommends that individual and small group practices have a baseline audit of their claim development and submission process. These audits help to ensure compliance with Medicare standards and may be conducted by an outside party such as a billing company or consultant.

And last but not least, you need to have a plan for dealing with any compliance issues that do arise. This should include an investigation process as well as corrective action plans. By having all of these elements in place, you can help ensure that your organization is compliant with Medicare requirements.

5. Meeting Quality Standards for Medicare Compliance

One of the most important requirements for Medicare compliance is continuous quality improvement. You must have a system in place to track and trend data, identify issues and problems, and then put corrective action plans in place to address those issues.

Your organization's quality improvement activities must be aligned with its strategic goals, and you must be able to show that your quality improvement efforts are improving the quality of care that your patients receive.

To meet this requirement, you'll need to have a quality management plan in place that outlines how you'll identify and address quality issues. You'll also need to track data and be able to show how your quality improvement efforts are making a difference.

6. Updating Provider Record Data and Re-enrollment

One of the most important things to remember regarding Medicare compliance is keeping your provider data up-to-date. If you move, change your name, or your credentials expire, you need to update your information in the Provider Enrollment Chain and Supplier System (PECOS).

You're required to revalidate your Medicare enrollment record periodically, and the process must be completed within 60 days of the date on your notice. The Centers for Medicare & Medicaid Services (CMS) will send you a message before your revalidation is due, and you can find more information about the process on their website.

PECOS supports the electronic Medicare enrollment process; you can use it to make changes to your provider enrollment record. You'll need to log in with your user ID and password, and then select the "Manage Change Request" option from the "Actions" menu. From there, you'll be able to update your information and submit it for review.

Once you've made all of the necessary changes, you'll need to submit a new enrollment application. You can do this by logging into PECOS and selecting the "Apply for Enrollment" option from the "Actions" menu. After that, you'll just need to follow the instructions on the screen to complete your application.

7. Improving Compliance with Medicare Practices

In this step, healthcare providers of Medicare need to develop standards of conduct specific to Medicare billing and reimbursement practices. Staff should be trained on these standards and held accountable for them. You should also perform regular auditing and monitoring functions to ensure compliance.

If you discover any non-compliance, take corrective action immediately. This may include retraining staff, modifying procedures, or taking disciplinary action against employees who violate the standards.

You should also report any instances of fraud or abuse to the proper authorities. By taking these steps, you can help ensure that your organization complies with Medicare billing and reimbursement practices.

Working with Regulatory Agencies

Working with regulatory agencies can be a daunting process, but it is a necessary one if you want to ensure compliance with Medicare in regulations. The first step is to understand which agencies are involved in the Medicare compliance process. The Centers for Medicare and Medicaid Services (CMS) is the primary federal agency that oversees the Medicare program, but there are also state agencies that have a role in overseeing the quality of care provided by skilled nursing facilities (SNFs).

The next step is to develop a good relationship with the regulatory agencies. This can be done by maintaining regular communication, being responsive to requests for information, and addressing any concerns that arise in a timely and professional manner.

Finally, it is important to have the plan to respond to regulatory audits and inspections. This plan should include steps for ensuring that all required documentation is readily available, as well as procedures for addressing any deficiencies that are identified.


As can be seen, there are several steps that healthcare providers must take to achieve Medicare compliance. By following the guidelines set out by the federal government, providers can minimize the risk of audits and optimize their reimbursement rates.

About the Author: 

Joni Ogle, LCSW, CSAT, Chief Executive Officer at The Heights Treatment has over 25 years of clinical experience, management, and leadership in working with adults and young adults suffering from addiction and trauma. She is a licensed clinical social worker and a certified sex addiction therapist with additional training in Recreational Therapy, Pia Mellody’s Post Induction Therapy, and Dr. Brene Brown’s The Daring Way Shame Resilience curriculum.

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