Face-to-Face, Direct Solicitation and PECOS Addressed — or Not — on Open Door

BALTIMORE — On an Open Door Forum call Jan. 19, CMS
officials made a string of announcements and answered a range of
caller questions, some going over old territory and some completely
unexpected.

For starters, the agency’s Lori Anderson told listeners that
despite the announced Jan. 1 implementation date for verification
of face-to-face encounters now necessary for both home health and
hospice benefits, CMS would not expect full compliance with the new
requirements until the second quarter of 2011. Anderson said the
agency had concerns that “some providers may need additional time
to establish operational protocols necessary to comply with these
requirements.”

DME providers, however, didn’t exactly get the same relief.

“Have you issued any guidance on whether or not you have started
implementing the face-to-face requirement for DME suppliers as
well?” asked a caller.

“No, that is a different statutory requirement,” Anderson
replied, adding that “the implementation regulation associated with
that is still in process.”

“Any idea when that might come out?” the caller inquired.

“No, I don’t know that,” Anderson replied, “but at the next Open
Door Forum we can try to get someone in here to give us an
update.”

Providers did get something of a reprieve on enforcement of the
expanded direct solicitation ban, included in CMS’ August 2010
final rule on
supplier standards.

“Among other things, the final rule included expansion of the
provision regulating the direct solicitation of Medicare
beneficiaries by DMEPOS suppliers,” explained the agency’s John
Spiegel.

“The new rule enlarged the scope of the provision beyond
telephone contacts to include in-person contacts, email and instant
messaging. Since then, unanticipated issues have arisen regarding
implementation of the newly expanded portions of the provision. CMS
feels further investigation is necessary to determine the best way
to apply these changes.

“In the interim,” Spiegel said, “CMS does not intend to instruct
Medicare contractors to implement the expanded provision.”

In other announcements/Q&As during the Open Door call:

• “We’ve noticed that sometimes physicians will fall off of the
  current PECOS list,” a caller said. Why is that, she asked?

  One CMS official responded, “I don’t have a good explanation.”
  But Spiegel said there could be a number of reasons, such as
  physician applications that haven’t been processed, problems in
  completing the enrollment review or information that physicians
  didn’t send in time, “things like that. And when it exceeds time
  limits for processing … sometimes things recycle and end up
  starting over again,” he said.

  Those are reasons physicians might not appear on the PECOS
  “pending” list, the caller pointed out, but that doesn’t explain
  why physicians might appear on the actual “approved” list only to
  disappear from that list later.

  Spiegel responded that if providers are having problems figuring
  out whether physicians are PECOS-registered, they can call
  410/786-5704 “and we’ll find an answer to your questions.”

• “Several of our doctors have complained they have tried to
  register for PECOS but it’s not showing up as even pending, and
  they’re telling us that CMS is backlogged. Is that true?” another
  caller wanted to know.

  Said Spiegel, “There is a backlog at the moment our contractors
  are working to resolve, so, yes, that’s true, there is a
  backlog.”

• CMS’ Susan Webster said Cigna, the Jurisdiction C DME MAC, is
  individually contacting any provider that had more than 200 claims
  denied as a result of an internal claims edit error on Jan. 3. That
  process “should be completed this week,” Webster said. (Read a
  notice on the Cigna website.)

• Webster also reminded non-contract grandfathered suppliers to
  use the KY modifier on claims for beneficiaries residing in a
  competitive bidding area “for purchased, covered accessories or
  supplies furnished for use with rented grandfathered equipment.
  There are 24 codes that fall into that category” in the CPAP,
  hospital beds and walker categories, Webster said. “Suppliers must
  use the KY modifier to receive payment, and they are reminded to
  please submit the single payment amounts as their submitted charge
  so their claims will process correctly.” (Additional information is
  included in a revised issue of MLN SE1035.)

• Do contract suppliers need to use a special modifier on their
  claims to identify themselves as contract suppliers, a caller
  wanted to know? No, said a CMS official. “For competitive bidding in general,
  the claims are identified in the system based on the beneficiary’s
  address, the zip code in the address, and the item is identified
  based on the HCPCS code and the supplier is identified based on a
  file we have with all the contract supplier numbers. So that’s how
  the competitive bidding claim is identified and a competitive
  bidding supplier is identified, and there’s no modifier that’s
  used.”

For a replay of Wednesday’s Open Door Forum, call 800/642-1687
and use Conference ID 29116124 (available for 10 business days
after the call).

The next Home Health, Hospice & DME Open Door Forum is
scheduled for Wednesday, March 2, from 2 to 3 p.m. ET. To listen
in, call 800/837-1935 and use Conference ID 39057815.