No ‘Get Out of Jail Free’ Card on the PECOS

ATLANTA — While providers now have ready access to spreadsheet-type data files that list both physicians who are PECOS-registered and those whose registration is pending, the system is clearly still a work in progress.

A recent notice from CMS said while more than 800,000 physicians and other health professionals have enrolled and have approved applications in PECOS, “some providers have encountered problems.” Earlier this month, the National Association of Chain Drug Stores (NACDS) and the National Community Pharmacists Association (NCPA) faxed an urgent plea to more than 62,000 doctors’ offices asking them to enroll or update their enrollment in the system.

Many Medicare claims — an AAHomecare survey suggests 23 to 30 percent — are still receiving CEDI error messages related to physicians who are not PECOS-registered. And only 2 percent of respondents to an informal June poll on HomeCare’s website said all of their referring physicians would be registered in the Medicare electronic enrollment system by July 6.

About that compliance date, CMS has said it won’t implement edits that will automatically reject a claim if a physician is not in the system until January. But the agency has not said it won’t go back and recoup monies for claims submitted with orders written by physicians who weren’t registered in PECOS by July 6.

“If you bill for anything after July 6, 2010, with a physician who is not PECOS-registered, you are at risk of having your payments recouped. PERIOD,” the National Association of Independent Medical Equipment Suppliers wrote in its newsletter last week.

But Medicare consultant and reimbursement specialist Andrea Stark of MiraVista LLC said providers should not be concerned because CMS has not provided a blanket statement ruling out future recoupment.

“CMS has clarified that they are not going to give DME a blanket ‘get out of jail free’ card. They have to stop short of giving a blanket release. What they have come out with and reiterated is that ‘PECOS is one tool, but we understand that there are doctors who have not registered, so we are using other tools to verify that they are eligible.’ In my mind, I am comfortable telling providers that as long as you can tell the referral source is legitimate, it’s OK to take the orders. But we still need to get those doctors in the system, because January will be here before you know it.”

Stark contends that whether a physician is currently listed in PECOS will not make a claim more likely to be subject to recoupment. While HME providers face an ongoing liability if they accept a referral from a physician who isn’t Medicare-eligible, that liability is no greater because a physician is not listed in the PECOS database.

“It’s time to calm people’s fears,” said Stark. “We don’t want to value form over substance. We don’t want to say PECOS is the be-all-end-all and exclude orders because [physicians] aren’t in this database.”

Stark said HME companies do “need to be active in managing physician eligibility to the extent that they always are. Maybe there are a few more steps, but it is not such a grave departure from what a supplier is already doing. There is always a liability that if you accept an order from a physician who doesn’t have the credentials or isn’t eligible that would be a fraud case against that physician.

“Providers should go through reasonable assurance to make sure an order is from an eligible referrer. Then it’s OK to go ahead,” Stark said. “The PECOS database is not where it needs to be in order to be relied on completely. If doctors aren’t listed in there, just take a couple of steps to make sure they are legitimate [before submitting claims].”

Dealing with the PECOS at this point, however, is proving to be a burden for many HME providers, including Advanced Home Care, Greensboro, N.C.

Kim Brummett, vice president of reimbursement and contracting, said the provider is in the process of switching software applications and is having to check four different databases — spanning old and new systems and serving the company’s home health agency, DME and infusion businesses — against PECOS enrollment.

Two full-time employees have been working on the verification effort for the last week, and there are also additional costs related to training the sales staff. Of 23,000 physicians in one database, Brummett said, 9,000 apparently are not PECOS-enrolled, although they are active to the point of referring a patient in the last six months.

“It’s pretty brutal,” said Brummett.

“We’re still running about 25 percent of our claims [receiving edits],” she said. “A challenge for us is that we have a lot of patients currently on service who started before the requirement. For example, if a patient got a wheelchair five years ago before capped rental went away, that physician may not be PECOS-enrolled.

“It would be great for them to consider grandfathering-in anyone who was before the requirement,” Brummett added.

In fact, the ordering/referring file now available from the system, updated on July 15, is even more current than that used to generate CEDI warning messages, Stark said, which explains why some recent claims referred by eligible physicians triggered error warnings.

She said MiraVista had recently learned that CEDI’s list of PECOS-enrolled physicians is incomplete, which could result in the incorrect firing of warning messages for enrolled physicians. The CEDI is working to update its records, she said.

Bottom line, according to Stark, if you are able to match the physician’s NPI and exact spelling of their first and last name in CMS’ list of PECOS-enrolled physicians, then those claims should not result in rejections beginning Jan. 3.

CMS has also sent a letter to physicians reiterating the need to register in PECOS. There are now even incentives for physicians to register related to becoming a paperless office that relies on electronic records.

“I believe we have the tools we need, it’s just a matter of timing and education at this point,” said Stark, who’s planning a Thursday (July 29) Webinar on the issue. “I don’t know if all the pieces will come together by January, but I don’t think there are any critical deficiencies at this point. We just need to get the doctors into the system,” she said.

“We’ll have to revisit it come January. It’s not going away.”