PECOS Doors Open to HME Providers; Physician Registration Still Troublesome

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
[email protected].