Enroll to avoid being denied by CMS
by Mary Ellen Conway
January 6, 2014

After several retractions, CMS announced that Jan. 6, 2014, is the day that Phase Two of the Internet-based Provider Enrollment, Chain and Ownership System (PECOS) will go into effect. PECOS is the system created by CMS to ensure that only vetted and acknowledged (enrolled) and appropriate prescribers prescribe certain services and products in the home care community. After Jan. 6, 2014, CMS will deny all HME, Part B and Part A home health agency claims that are submitted by providers with products and/or services ordered by health care professionals who are not enrolled in the PECOS system. You might remember that PECOS was ready to be implemented a few years ago, but at the last minute, CMS decided to put the start date on hold. At the time, a very small percentage of prescribers actually were enrolled in PECOS, and the new online system was complicated and lengthy. Due to the extremely high number of warnings that HME providers were receiving, AAHomecare immediately asked CMS to take a much more measured 
approach and delay the start of Phase 
Two until data showed that the vast 
majority of ordering clinicians were enrolled in the system. And now that date is here. Since 2011, suppliers have been receiving warning notices for submitted claims with clinicians who are not enrolled in PECOS. Hopefully, you and your staff have not been ignoring these edits for the last few months and have spoken to your non-enrolled prescribers. “CMS indicates that they have taken proactive steps to enroll ordering and referring providers,” said AAHomecare officials in a message to members. They are ready to launch the program. CMS estimates that less than 1 percent of ordering clinicians have not enrolled in PECOS. Do you think that less than 1 percent of your prescribers are not enrolled? Most of my clients say no, that it is much higher. This presents a challenge for you. Are you going to take referrals from prescribers who are not enrolled? The answer is no. These prescribers have been receiving edits on their own claims for Part B services for months, warning them that they must be enrolled. You and your peers in HME and home care who receive referrals from them have been (or should have been) warning the prescribers as well. There is no retroactive process to pay claims if the prescriber does not enroll in PECOS until after this effective date. Your claims will be unpaid and not paid on resubmission. You must stop taking referrals from non-enrolled prescribers right away. Realize that all post-acute providers will not be accepting those referrals, as none of them will be paid. As soon as they are enrolled, you can return to accepting their referrals again. If you have providers who are not enrolled as of the effective date, you can do two things. Print the PECOS application and enrollment materials, with the instructions, and bring them to your non-enrolled prescribers. Hand them the copies and explain that you, and other post-acute providers, are no longer able to bill Medicare for their patients and that you can no longer accept referrals as of Jan. 6. Avoid unnecessary denials and ensure that you are submitting claims using an individual clinician’s National Provider Identifier (NPI) rather than an organization NPI. Many practices have been accustomed to providing an organizational NPI with referrals. While CMS has tried to discourage this during the past years, some are late to implement the change and get updated NPI numbers for each practitioner, even though they have had a few years to get this done. Your accreditation organization may have sent you information on this requirement, but you have been receiving this information on your claims from your DME MAC for years. Surveyors conducting accreditation surveys after Jan. 6 
will certainly ask to see the process 
you have in place for maintaining your current listings of PECOS enrolled providers. PECOS enrollment is not just 
a requirement to get your claims paid 
but also an accreditation requirement 
to be in compliance with all payer 
requirements.