Despite Delay, PECOS Remains ‘Mission Critical’

COLUMBIA, S.C. — Even though CMS has delayed the PECOS physician registration requirement until April 5, 2010, industry consultant Andrea Stark is counseling HME companies not to slow down on educating referral sources about the new rule.

“Don’t change anything that you’re doing,” said Stark, founder of MiraVista LLC. “Proceed as if this is Mission Critical, because rejections are ultimately inevitable if you do nothing.”

During a Nov. 19 teleconference on the PECOS sponsored by the American Association for Homecare, Stark told listeners to “proceed as if this is going to happen and rejections are going to take place.” A few days later on Nov. 23, CMS sent notice of the three-month delay, but Stark said that’s still her advice.

“There is not enough driving force on physicians to get it done without an external influence,” she said. And come April 5, DMEPOS claims will reject unless the ordering physician is registered in the system.

The phase-in grace period for the new policy would have ended on Jan. 4, but CMS said extending the implementation date would give physicians and others eligible to order/refer sufficient time to enroll, or re-enroll, in Medicare. According to Stark, thousands of physicians enrolled in Medicare before PECOS became available.

She speculated that a number of those physicians haven’t registered in the Internet-based system simply because they are already registered with Medicare. “They think they’re fine,” Stark said. “Most are enrolled with Medicare and on file with Part B and they’ve got NPI numbers,” so many doctors may not understand there’s a reason to register in the system, she said.

“CMS has tried to put some skin in the game for doctors,” Stark noted. “They are contacting the top 50 doctors in every state if they are actively billing and they are not in PECOS. There is also a mass mailing to every doctor in every state reminding them of their onus to keep their information updated.”

If that letter, a special mailer addressed to the individual physician, gets returned “for whatever reason,” Stark said, “the contractors have been instructed to revoke billing privileges for that physician.”

Even so, she said, “You have to keep that in perspective. The [special mailer] helps to deliver the message that CMS is serious about this enrollment initiative … and it will help providers to deliver the message.” But the number of doctors who are actually going to have returned correspondence will be limited, Stark pointed out, and the number of doctors who are currently not in the system is high (the AMA estimates more than 200,000). So providers must continue to make sure their physicians and other referrers get registered.

“It buys us some time,” Stark said of the delay, “but it’s not perfect. That’s why providers cannot afford to be lackadaisical about it.”

Stark added that for physicians completing enrollment applications online, 90 percent are usually processed within 45 days. If the application is on paper, it takes an average of 90 days for processing. That’s another reason for HME providers not to let up on their efforts with physicians, she said.

“Depending on how the doctors are going to submit their applications will determine how many more we can get into the system [by April 5]. I don’t know that the contractors have ever had a deluge of applications come in like this before,” Stark said. “We could be looking at a 90-day best-case scenario assuming they are on top of things.”

Providers are currently receiving warning edits on claims if the ordering physician is not enrolled in the PECOS. If a physician is still not registered as of the cutoff date, Stark said, those claims “will be unprocessable” and will reject. If the physician gets his or her enrollment updated in PECOS after April 5, then the doctor “will be valid as if there was never a problem, so any claims that were rejected can be resubmitted as clean claims.”

She reiterated that CMS has promised tools to help, including a physician-searchable database and an update of PECOS records to include NPI numbers, “but we have no specific ETA for that except ‘prior to the implementation of Phase 2′” when the claims edits become effective.

Stark said at some point, online registration in the PECOS may also be available for DMEPOS providers. “I’ve heard rumors it could possibly be by the end of next year, but I wouldn’t count on it,” she said. “That would have been so wonderful in September and October when we had this mad dash to get in all of the surety bonds and accreditation status.”

Some tips from Stark, who fielded specific questions on the teleconference:

• Monitor warnings. Make sure you get to your highest-priority physicians if you discover they are not registered.
• While waiting for the searchable database of physicians in PECOS, use Medicare.gov as “the next best thing.”
• Use all caps for the physician name when you bill, and use only the physician’s legal name. “Check that the first initial of the first name and then the first four characters of the last name are all being transmitted correctly (not being transposed) and that they match the legal name of the doctor.”
• Use the physician’s individual NPI number, not the group NPI.
• Eliminate titles on the physician name. “That could cause an error in the validation,” Stark said. “The title should not be submitted, just the first name and the last name of the referring physician.”

According to CMS, more detailed information about the PECOS will be published in an upcoming MLN Matters article.

Read the entire CMS notice about the delay.