BALTIMORE—In another move to establish barriers to fraud and abuse within the Medicare system, CMS announced this week that beginning Oct. 11, home medical equipment providers would have access to PECOS, the online Medicare enrollment system.
Providers have been waiting months for access to the Provider Enrollment, Chain and Ownership System, which will allow them to view and update enrollment information, submit requests for re-enrollment applications, voluntarily terminate from the Medicare program and track the status of applications submitted via the Internet.
“Ultimately, PECOS will reduce the time necessary for suppliers to enroll or make changes in their Medicare enrollment and allow suppliers to view their Medicare enrollment information for accuracy while reducing the administrative load associated with processing Medicare enrollment information,” according to CMS.
While it’s a step in the right direction for DMEPOS enrollment, stakeholders said, it still doesn’t address industry worries over physicians who may not have registered in the online database. As of late July, many claims were still generating CEDI error messages about physicians who were not PECOS-registered; a survey from the American Association of Homecare suggested 23 to 30 percent.
Under the Affordable Care Act, only Medicare-enrolled physicians or eligible professionals can certify or order HME for Medicare beneficiaries. The PECOS should make it easy to check their status, according to CMS. But the health reform law also set a July 6 deadline for enrollment in the system, and on Jan. 3, 2011, the agency plans to implement edits that will automatically reject a claim if a prescriber does not show up in PECOS.
The key sticking point is that providers submitting claims from July 6 to Jan. 3 fear they could be required to return Medicare payments if the certifying or ordering physician was not enrolled in the system by the deadline. So far, the agency has not definitely said it won't go back and recoup monies for such claims.
According to AAHomecare’s Walt Gorski, vice president of government relations, the issue is still unclear. As for the latest announcement on HME providers’ use of the PECOS themselves, Gorski said, “All we know is that the window has opened up mandated by legislation. It’s another provider screening tool to reduce fraud and abuse, and we encourage home care providers to register as quickly as possible.”
B.J. Bowser, a former provider and consultant with Sherman Oaks, Calif.-based Lieber Consulting, echoed the urgency of getting enrolled—for physicians. “I’m saying don’t wait. It is taking so much time,” Bowser said, noting that the backlog is such that it can take a month or more to be registered in the system.
That’s another sticking point about the PECOS. CMS has placed the onus for getting physicians enrolled on providers, a responsibility that has outraged many who say it is unfair, time-consuming and frustrating.
“The physicians have no incentive. They are getting paid for their patients’ exams, and whether we get paid for a walker or a wheelchair is of no concern to them,” said Tony Martinelli, owner and president of Med World HME in Santa Maria, Calif.
Bowser said providers she has worked with also continue to get pushback from physicians, who say they have not been alerted by CMS that they have to be enrolled and thus do not see the need to do so. Still, she said, “I am instructing all the companies I work with to get it done. If we don’t get our physicians signed up, are we going to be losing that money?
“Companies are smart to be proactive, because Medicare can always be retroactive [in denying claims],” she added.
She recognizes that providers have little to no leverage in getting physicians to do anything. However, she has found one method that appears to work.
“In every company I am working with right now, I am having them talk to the physician but in addition, I am having them all go to the office manager,” Bowser said. “We are putting that burden back on them and saying, ‘I know you are responsible, and if you don’t get this done, the doctor is going to have a hard time getting Part B [prescriptions] covered by Medicare because no DME company is going to accept your patients.’”
Bowser’s clients follow that up with a paper listing the implementation date and the next steps for the office manager to take to register the physician. “It’s whatever it takes to make it easier. We want to get them enrolled,” she said.
Come January, it could be a devastating problem for providers whose referral sources remain unregistered in the system. Bowser said some industry software automatically alerts the user to claims that could be rejected because the physician is not enrolled in PECOS. The average, she said, is about 50 claims a day for companies using the software.
“We just can’t afford to not be proactive and let Medicare come back and take that money,” Bowser said. “Most businesses cannot afford to float the money.”
Both she and Martinelli said that, in the end, the beneficiary could be the one who is hurt the most.
Before accepting a physician’s order, Med World will check whether or not the referral source is in PECOS. If not, Martinelli said, he’ll have to explain to the patient why he can’t bill the item to Medicare. “We’ll have to bill it not assigned,” he said. The only other option, he said, would be for the beneficiary to get a new prescription from a physician who is in PECOS.
“Can you imagine patients having to choose their provider based on whether their physician is registered with PECOS or not?” Bowser asked rhetorically.
For his part, Martinelli wonders if it is all worth it. Will PECOS achieve CMS’ ultimate goal of deflecting fraud and abuse?
Martinelli thinks not, because, he says, CMS does not police the systems it puts in place. A 16-year veteran of the HME business, he said on numerous occasions over the years he has reported fraudulent incidences to Medicare, such as companies billing for new power wheelchairs and delivering second-hand chairs or scooters instead.
“You never get to talk to a live person. I’ve never had a return call or a return letter,” he said, adding that he has taken reams of documentation to the FBI and has been told the agency is “too busy” with other crimes.
“We have people that have for the last five years been advertising power chairs and they don’t have an ATP on staff, some are not accredited, one person works out of their home—they don’t even have a real location. Why aren’t they out of business?… A provider should be able to call up and talk to a live person and have [the situation] investigated right away,” Martinelli said.
“PECOS isn’t going to do a thing to stop fraud,” he predicted.
But it could stop Medicare beneficiaries from getting what they need unless they can afford to pay for equipment themselves.
“They are going to end up buying their own commode,” Martinelli said.
For additional information on using the PECOS, CMS said providers should review the “Getting Started Guide” on the CMS website.
For navigation or access problems, contact the External User Services help desk at 866/484-8049 or e-mail the EUS Help Desk at EUSSupport@cgi.com.
