Say What about the PECOS?

BALTIMORE — The question has been asked any number of
times now in any number of ways: What exactly is the deal with
PECOS compliance regarding DME claims?

The industry’s latest attempt at getting a straight answer came
from the American Association for Homecare’s Walt Gorski, vice
president of government affairs, on a CMS Open Door Forum July
7.

The background:

The deadline for physician and other prescriber enrollment in
the Provider Enrollment, Chain and Ownership System was Jan. 3,
2011, but in order to be compliant with the new health reform law
(Affordable Care Act, or ACA), CMS pushed that deadline up to July
6 in an interim final rule.

In a June 30
announcement, the agency said it would “for the time being not
implement PECOS edits 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.”

But the announcement gave providers no assurance that, in future
audits, they wouldn’t have to give back their Medicare
reimbursements based on claims submitted from July 6 to Jan. 3 if
the ordering physician was not enrolled in PECOS.

So, AAHomecare’s Gorski asked:

“Will [you] address that specific issue, that CMS and its
contractors will not seek recoupment from claims that are receiving
warnings during this period?”

Jim Bossenmeyer, CMS director of provider enrollment, responded
this way:

“There are a number of reasons why Medicare may recoup
money.”

He added that DMEPOS suppliers should:

• Make sure their claims contain the legal name of the physician
  or other eligible professional along with their Type 1 NPI;
• Make sure the individual is licensed to practice in the state
  and has not been excluded from the program by the Office of
  Inspector General;
• Keep documentation from orders for services referred to them;
  and
• Work with their referral sources to make sure they know there
  is a requirement for PECOS enrollment.

Gorski tried again: “If we do that and a ZPIC or RAC audit
occurs in 2012 and they look and see the effective date of the IFR
and see that the referring physician was not enrolled in PECOS, you
are telling the supplier community that the money will not be
recouped?”

To which Bossenmeyer replied: “I have not said that. I
understand what you would like me to say, but I cannot give you
that answer today.”

The comment period for the IFR closed July 6. “At some point,”
Bossenmeyer said, “CMS, after we have gone through looking at the
public comments, will make a decision regarding the implementation
of systematic editing.”

One more try from Gorski: “If that is the case, what do
[suppliers do if they] get a referral from a physician that is not
PECOS-enrolled?”

Said Bossenmeyer: “What I’m suggesting to you is that most
physicians have an enrollment record in PECOS.” There are 26,000
more physicians and 3,400 more non-physician practitioners in the
system’s “pending” file that are currently going through the
enrollment process, he added.

“DMEPOS suppliers know the physicians they work with and they
know the non- physician practitioners they work with,” Bossenmeyer
said. “They should submit compliant claims.”

With that, AAHomecare reported in its July 8 newsletter, the
association “continues to press CMS for clear and unambiguous
guidance and is working with providers and patient groups to
address our concerns.” And there are a lot of them.

In an eight-page letter sent to CMS, the association formally
requested a delay in enforcement of PECOS regulations. The letter
reads, in part:

Under the circumstances, it would be patently unfair for CMS
and its contractors to reopen claims as a means of enforcing ACA
compliance. DMEPOS providers, at best, have only limited influence
over what their referral sources do.

More importantly, the IFR offers zero guidance with respect
to what providers must do to demonstrate their compliance with the
new rules. Although we appreciate the steps CMS is taking to soften
the impact of the rule, the potential that providers, whose claims
get paid after July 6 but before CMS implements rejections for
ordering/referring physicians, will nonetheless be at risk for
recoupments based on audits. This will affect HME providers’ cash
flow in ways that can be disruptive to patient care.

Consequently, we request that CMS delay the rule and its
enforcement until January 3, 2011, at the earliest.

Further, because our experience proves how difficult it is
to motivate referral sources to comply with these rules, we
strongly recommend that CMS publish the percentage of physicians
and eligible professionals enrolled in PECOS as of November 30,
2010. If the percentage of providers who are not enrolled in PECOS
is greater than five percent of the total number of prescribing
physicians and eligible professionals nationwide, CMS should delay
the implementation date until this target is met.”

Also on the Open Door call, Bossenmeyer said DMEPOS suppliers
would not able to use the PECOS system themselves “until the fall
of this year.”

CMS had previously said the system would be open for DMEPOS
enrollment in July.