No New News in PECOS Announcement — and That Isn’t Good News

BALTIMORE — In response to a nationwide uproar in the
physician, pharmacy and home medical equipment communities over a
July 6 compliance
date for physician/prescriber enrollment in PECOS, CMS issued a
statement June 30 saying it was reviewing the process.

“CMS will, for the time being, not implement changes that would
automatically reject claims based on orders, certifications, and
referrals made by providers that have not yet had their
applications approved by July 6, 2010,” the agency said.

CMS’ announcement that it is working to address the concerns of
the various stakeholders didn’t change anything, those in the HME
sector said.

Under the Affordable Care Act, only Medicare-enrolled physicians
or eligible professionals may certify or order for Medicare
beneficiaries such services as home health, home medical equipment,
prosthetics, orthotics and supplies. To be considered enrolled,
they must have records in the Internet-based Provider Enrollment,
Chain and Ownership System. The initial deadline for
enrollment and implementation was Jan. 3, 2011, but CMS said in
order to be compliant with the new health reform law, it had to
push the enrollment deadline up to July 6.

The statement did not address the key sticking point: That
providers submitting claims in good faith from July 6 to Jan. 3
could be required to return Medicare payments if the certifying or
ordering physician was not enrolled in PECOS.

“They just told us what we already know. [The statement]
basically restates the current state of play, which is that the
effective date is July 6 and the implementation date is Jan. 3,”
said John Shirvinsky, executive director of the Pennsylvania
Association of Medical Suppliers. “That has never been in question.
What has been in question is the [possibility of recoupment]
… Every claim that has been honored between July 6 and Jan. 3
can be recouped if the auditors decide that is the thing to do.

“There is a difference between getting paid and staying
paid.”

Wayne Stanfield of the National Association of Independent
Medical Equipment Suppliers agreed.

“It says the same thing, but implies that they will not enforce
it in a strange way by saying they will use a contingency plan to
assure only valid physicians are used,” he said. “I’m not at all
comfortable with this, but it is better than nothing.”

AAHomecare Wants Clarification

The American Association for Homecare said it was pleased at
CMS’ announcement, but added “the association remains extremely
concerned, based on the extent of auditing activity that HME
providers are now confronting, that HME providers may still be
vulnerable to future recoupment activities from post-payment
audits. We are working with CMS staff to seek additional
clarification and guidance on this issue.”

HME providers, physicians and others have complained in vast
numbers to CMS about the recoupment issue as well as the
deadline.

AAHomecare sent a letter to CMS last week setting out its
concerns with the PECOS edits on HME claims. Noting that “patient
access to care and disruptions in provider payments will inevitably
occur unless CMS delays the implementation date,” the organization
recommended that CMS:

• Adhere to its original Jan. 3, 2011, deadline;
• Publicize, in December 2010, the percentage of physicians and
  eligible professionals enrolled in PECOS and delay the
  implementation date unless that figure is greater than 5 percent of
  the number of prescribing clinicians nationwide;
• Grandfather Medicare claims for DMEPOS items and services
  billed on a monthly basis, such as capped rental items, and for
  those items that Medicare continues to pay a maintenance and
  service fee;
• Instruct contractors that claims that are not PECOS compliant
  not be subject to recoupment based solely on the PECOS-related
  issues between July 1, 2010, and the implementation date;
• Develop a searchable database that can be imported into a
  supplier’s computer system to determine if prescribing clinicians
  are enrolled in PECOS.

To view the full letter, see the AAHomecare website.

Pharmacists, Physicians Worried, Too

Complaints have also arisen in other health care camps. NAIMES
reported that the National Association for Homecare & Hospice
has generated nearly 1,000 calls to Congress about PECOS over the
past few days.

The National Association of Chain Drug Stores has also been in
discussion with congressional leaders about the issue and is
submitting comments to CMS. An NACDS statement noted its members
“are already confronting 30 percent rejection rates on their
Medicare Part B claims due to the fact that providers are either
unaware or not properly enrolled in PECOS.”

At its meeting in Chicago this week, the American Medical
Association called on CMS “to return the deadline for enrolling in
[PECOS] to Jan. 3, 2011.”

Meanwhile, HME providers have been working to get their referral
physicians enrolled in PECOS, a job CMS has said is essentially
theirs.

Shirvinsky said CMS is not doing much to get physicians
enrolled.

“They have sent out, to my knowledge, two notices to physicians.
That compares with the three notices a week for two-and-a-half
years about complying with the [National Provider Identification]
process,” he said.

In any case, it would be tough to get every physician enrolled
by July 6. The system is reportedly backlogged, with a three- to
six-month waiting period to obtain PECOS registration, Shirvinsky
said.

CMS has said that PECOS warnings have dropped from 6 million per
month to 3 million, “but 3 million is still a very large number,”
Shirvinsky said.

Providers can take some steps to protect themselves, according
to NAIMES. The organization suggested that providers say no to all
referral requests from physicians not registered and explain the
risk of having payments taken back; consider calling patients with
capped rental, long-term oxygen and the like whose physician is not
registered and changing their claims to non-assigned; and encourage
Medicare patients to contact their legislators and alert them to
the difficulties with the current PECOS rule.

“Have them tell Congress that the physician must be held
accountable, not the provider taking the referral,” NAIMES
urged.

Read the full CMS announcement.