Eliminating Billing-Privilege Gaps: A PECOS & NPPES Reconciliation
Restored
Billing Privileges
Identified & fixed
Data Inconsistencies
PECOS/NPPES aligned
Enrollment Records
Ongoing quarterly
Monitoring
How Medeoan reconciled mismatched PECOS and NPPES records after an acquisition, cleared a revalidation hold, and restored a home health agency’s billing privileges.
The Challenge
A multi-location, Medicare-certified home health agency had recently absorbed a smaller competitor through an acquisition. In the transition, the acquired agency’s enrollment data was carried over without a full reconciliation — leaving several service locations with a Medicare service address in PECOS (Provider Enrollment, Chain, and Ownership System) that no longer matched the practice-location address on record in NPPES (National Plan and Provider Enumeration System). What looked like minor clerical drift was, in Medicare’s eyes, a data-integrity discrepancy tied to the provider’s NPI. Because PECOS validates enrollment data against the NPPES record associated with each NPI, the mismatched addresses began causing claims for some of the affected locations to be rejected at the front end. When the agency entered a scheduled revalidation cycle, PECOS 2.0’s enhanced data-validation logic surfaced every inconsistency at once and flagged the enrollment as incomplete — triggering a provisional hold on the agency’s billing privileges for the impacted locations and putting a growing block of Medicare reimbursement at risk.
Our Solution
Medeoan’s credentialing team began with a full cross-system audit, comparing every field across PECOS, NPPES, and the agency’s internal enrollment and licensure records for each NPI and practice location. This surfaced the exact points of divergence — chiefly the outdated service addresses inherited through the acquisition — and separated true data errors from records that were simply out of sync between systems. With the discrepancies mapped, we verified each service location against authoritative documentation and reconciled the records so that the practice-location addresses in NPPES matched the enrolled service addresses in PECOS for every affected NPI. We then prepared the revalidation submission — confirming ownership, location, and authorized-official information — and submitted it through the agency’s Medicare Administrative Contractor (MAC), tracking each request through development-letter responses to final determination so nothing stalled in the queue. To keep the enrollment clean going forward, Medeoan implemented a quarterly data-consistency monitoring routine that re-checks PECOS and NPPES against the agency’s internal system of record. The goal is to catch address, ownership, or location changes before they age into a revalidation surprise — turning enrollment integrity into an ongoing operational habit rather than a periodic fire drill.