The following is a portion of the July 12 HomeCare Monday email discussing the current status of PECOS compliance. It’s bad enough that home infusion providers are being held for physician compliance, something they do not have control over, but reading this gave some real insight to the precarious position we are in and the lack of clarity from CMS.

Say What about the PECOS?
BALTIMORE—The question has been asked any number of times now in any number of ways: What exactly is the deal with PECOS compliance regarding DME claims?

The industry’s latest attempt at getting a straight answer came from the American Association for Homecare’s Walt Gorski, vice president of government affairs, on a CMS Open Door Forum July 7.

The background:

The deadline for physician and other prescriber enrollment in the Provider Enrollment, Chain and Ownership System was Jan. 3, 2011, but in order to be compliant with the new health reform law (Affordable Care Act, or ACA), CMS pushed that deadline up to July 6 in an interim final rule.

In a June 30 announcement, the agency said it would “for the time being not implement PECOS edits that would automatically reject claims based on orders, certifications, and referrals made by providers that have not yet had their applications approved by July 6, 2010.”

But the agency gave providers no assurance that, in future audits, they wouldn’t have to give back their Medicare reimbursements based on claims submitted from July 6 to Jan. 3 if the ordering physician was not enrolled in PECOS.

So, AAHomecare’s Gorski asked:

Will [you] address that specific issue, that CMS and its contractors will not seek recoupment from claims that are receiving warnings during this period?

Jim Bossenmeyer, CMS director of provider enrollment, responded this way:

There are a number of reasons why Medicare may recoup money.”

He added that DMEPOS suppliers should:

• Make sure their claims contain the legal name of the physician or other eligible professional along with their Type 1 NPI;
• Make sure the individual is licensed to practice in the state and has not been excluded from the program by the Office of Inspector General;
• Keep documentation from orders for services referred to them; and
• Work with their referral sources to make sure they know there is a requirement for PECOS enrollment.

Gorski tried again:

If we do that and a ZPIC or RAC audit occurs in 2012 and they look and see the effective date of the IFR and see that the referring physician was not enrolled in PECOS, you are telling the supplier community that the money will not be recouped?

To which Bossenmeyer replied:

I have not said that. I understand what you would like me to say, but I cannot give you that answer today.

The comment period for the IFR closed July 6.

At some point,” Bossenmeyer said, “CMS, after we have gone through looking at the public comments, will make a decision regarding the implementation of systematic editing.

One more try from Gorski:

If that is the case, what do [suppliers do if they] get a referral from a physician that is not PECOS-enrolled?

Said Bossenmeyer:

What I’m suggesting to you is that most physicians have an enrollment record in PECOS.” There are 26,000 more physicians and 3,400 more non-physician practitioners in the system’s “pending” file that are currently going through the enrollment process, he added.

“DMEPOS suppliers know the physicians they work with and they know the non- physician practitioners they work with,” Bossenmeyer said. “They should submit compliant claims.

What I’m suggesting to you is that most physicians have an enrollment record in PECOS.” There are 26,000 more physicians and 3,400 more non-physician practitioners in the system’s “pending” file that are currently going through the enrollment process, he added.

With that, AAHomecare reported in its July 8 newsletter, the association “continues to press CMS for clear and unambiguous guidance and is working with providers and patient groups to address our concerns.” And there are a lot of them.

In an eight-page letter sent to CMS, the association formally requested a delay in enforcement of PECOS regulations. The letter reads, in part:

Under the circumstances, it would be patently unfair for CMS and its contractors to reopen claims as a means of enforcing ACA compliance. DMEPOS providers, at best, have only limited influence over what their referral sources do.

More importantly, the IFR offers zero guidance with respect to what providers must do to demonstrate their compliance with the new rules. Although we appreciate the steps CMS is taking to soften the impact of the rule, the potential that providers, whose claims get paid after July 6 but before CMS implements rejections for ordering/referring physicians, will nonetheless be at risk for recoupments based on audits. This will affect HME providers’ cash flow in ways that can be disruptive to patient care.

Consequently, we request that CMS delay the rule and its enforcement until January 3, 2011, at the earliest. Further, because our experience proves how difficult it is to motivate referral sources to comply with these rules, we strongly recommend that CMS publish the percentage of physicians and eligible professionals enrolled in PECOS as of November 30, 2010. If the percentage of providers who are not enrolled in PECOS is greater than five percent of the total number of prescribing physicians and eligible professionals nationwide, CMS should delay the implementation date until this target is met.” Also on the Open Door call, Bossenmeyer said DMEPOS suppliers would not able to use the PECOS system themselves “until the fall of this year.” CMS had previously said the system would be open for DMEPOS enrollment in July.

Rock-Pond Solution’s PECOS Database Audit Tool is one way to assess your risk and do something about it NOW.