News in Healthcare: PECOS

information provided by
Health First Oxygen and
Home Medical Equipment

February 2010 update

In the wake of numerous complaints, CMS has changed the way it is implementing Provider Enrollment, Chain and Ownership System (PECOS) provider edits. These are the ineligible ordering/referring provider edits that most HME providers have become familiar with over the last few months.

The main changes you need to be aware of are:

Until April 5, 2010, if a referring or ordering provider is not registered with PECOS, you will receive an unauthorized provider warning.
On April 5, 2010, CEDI will stop issuing warnings and begin rejecting claims that do not pass PECOS provider edits.
Prior to April 5, CMS will provide a file with names and NPIs of Medicare providers eligible to order or refer in the Medicare program.

Additionally, if you receive ineligible ordering or referring provider edits,CMS recommends the following:

Contact the ordering/referring provider to verify his eligibility with PECOS.
Contact the ordering/referring provider to verify how his name is listed in his PECOS enrollment and ensure the name submitted on the claim matches the PECOS record.
Verify the Type I (individual physician’s) NPI and name of the ordering/referring provider is submitted on the claim. If the Type II (physician’s group) NPI and name is submitted, a match will not be found on the PECOS file.

We hope that this information will be helpful to you. If you have any questions, please contact your Medicare DME MAC Provider Contact Center.

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November 2009 update

PECOS IS DELAYED Until April 5, 2010

The Centers for Medicare & Medicaid Services (CMS) will delay, until April 5, 2010, the implementation of Phase 2 of Change Request (CR) 6417 (Expansion of the Current Scope of Editing for Ordering/Referring Providers for Claims Processed by Medicare Carriers and Part B Medicare Administrative Contractors (MACs)) and CR 6421 (Expansion of the Current Scope of Editing for Ordering/Referring Providers for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Supplier Claims Processed by Durable Medical Equipment Medicare Administrative Contractors (DME MACs)). CRs 6417 and 6421 are applicable to Part B claims only.

The delay in implementing Phase 2 of these CRs will give physicians and non-physician practitioners who order items or services for Medicare beneficiaries or who refer Medicare beneficiaries to other Medicare providers or suppliers sufficient time to enroll in Medicare or take the action necessary to establish a current enrollment record in Medicare prior to Phase 2 implementation.

Although enrolled in Medicare, many physicians and non-physician practitioners who are eligible to order items or services or refer Medicare beneficiaries to other Medicare providers or suppliers for services do not have current enrollment records in Medicare. A current enrollment record is one that is in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and also contains the physician/non-physician practitioner’s National Provider Identifier (NPI). Under Phase 2 of the above referenced CRs, a physician or non-physician practitioner who orders or refers and who does not have a current enrollment record that contains the NPI will cause the claim submitted by the Part B provider/supplier who furnished the ordered or referred item or service to be rejected.

CMS continues to urge physicians and non-physician practitioners who are enrolled in Medicare but who have not updated their Medicare enrollment record since November 2003 to update their enrollment record now. If these physicians and non-physician practitioners have no changes to their enrollment data, they need to submit an initial enrollment application which will establish a current enrollment record in PECOS.

For physicians and non-physician practitioners who order or refer—

If you are not enrolled in the Medicare program, or if you enrolled more than 6 years ago and have not submitted any updates or changes to your enrollment information in more than 6 years, you do not have an enrollment record in PECOS. In order to continue to order or refer items or services for Medicare beneficiaries, you will have to submit an initial enrollment application. You may do so either by (1) using Internet-based PECOS (which transmits your enrollment application to the Medicare carrier or A/B MAC via the Internet—be sure to mail the signed and dated Certification Statement to the carrier or A/B MAC immediately after submitting the application), or (2) filling out the appropriate paper Medicare provider enrollment application(s) (CMS-855I and CMS-855R, if appropriate) and mailing the application, along with any required additional supplemental documentation, to the local Medicare carrier or A/B MAC, who will enter your information into PECOS and process your enrollment application. Information on how to enroll in Medicare is found on the Medicare provider/supplier enrollment web site atwww.cms.hhs.gov/MedicareProviderSupEnroll.
If you are already enrolled in Medicare, make sure you have a current enrollment record. You can find out if you have an enrollment record in PECOS by calling your designated carrier or A/B MAC or by going on-line, using Internet-based PECOS, to view your enrollment record. We will be posting information to the Medicare provider/supplier enrollment web site that will guide you through this process. Information about Internet-based PECOS and a link to Internet-based PECOS can be found on the Medicare provider/supplier enrollment web site. Before using Internet-based PECOS, we recommend that you read the information that is posted there and that is available in the downloadable documents section.
If you are a dentist or a physician with a specialty such as a pediatrics who is eligible to order or refer items or services for Medicare beneficiaries but have not enrolled in Medicare because the services you provide are not covered by Medicare or you treat few Medicare beneficiaries, you need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries.
If you are a physician who is employed by the Department of Veterans Affairs, the Public Health Service, or the Department of Defense Tricare program but have not enrolled in Medicare because you would not be paid by Medicare for your services, you need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries.
If you are a resident who has a medical license but have not enrolled in Medicare because you would not be paid by Medicare for your services, you do not need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries. The teaching physician—not the resident—should be identified in claims as the ordering/referring provider when a resident orders or refers items or services for Medicare beneficiaries.

CMS actions to mitigate the number of informational messages:

Since many Part B providers and suppliers are receiving a high volume of informational messages in their Remittances, CMS is taking the following actions to reduce the number of informational messages being generated:

1. Prior to the implementation of Phase 2, CMS will systematically add the NPIs to the PECOS enrollment records of all physicians and non-physician practitioners whose enrollment records are in PECOS but do not contain their NPIs. Because the NPI is one of the matching criteria used in implementing the two new edits on the Ordering/Referring Provider, it is essential that the NPI be in the PECOS enrollment record. Because the data file used to implement the two edits contains only the eligible physicians and non-physician practitioners who are in PECOS with NPIs in their enrollment records, this action will add many more physicians and non-physician practitioners to that data file.

2. Prior to the implementation of Phase 2, CMS will make publicly available on the Internet the names and NPIs of the Medicare physicians and non-physician practitioners who are eligible to order or refer in the Medicare program. The name displayed will be that of the physician or non-physician practitioner as it appears in his or her PECOS enrollment record. This will allow Part B providers and suppliers who furnish and bill for items or services based on orders or referrals to determine if the Ordering/Referring Provider being identified in their claims will pass the two new edits prior to submitting the claims to Medicare.

3. Prior to the implementation of Phase 2, CMS will issue instructions to carriers and A/B MACs that will assist them in processing enrollment applications from physicians who are employed by the Department of Veterans Affairs, the Public Health Service, and the Department of Defense Tricare program. The instructions will also state that the teaching physician should be reported as the Ordering/Referring Physician in situations where a resident orders or refers items or services for Medicare beneficiaries. The instructions will also note that dentists and pediatricians, who sometimes order or refer items or services for Medicare beneficiaries, may be enrolling in Medicare in order to continue to order and refer.

4. CMS will be preparing a Special Edition Medicare Learning Network (MLN) Matters Article on the implementation of these two new edits. This MLN Matters Article will expand upon the information currently available in MLN Matters Articles MM 6417 and MM 6421.

Message for Congress: Resist Further Cuts to HME, Support Meek and LeMieux Bills
During the Thanksgiving congressional recess, remind your Senators and Representative to resist any further cuts to home medical equipment. Your Representative in the House should be reminded to cosponsor the bill introduced by Congressman Kendrick Meek (D-Fla.), H.R. 3790, which would eliminate the competitive bidding program in a fiscally responsible manner. Those who have already signed on as cosponsors should get a thank-you call or email.

Senators should be encouraged to support Senator George LeMieux’s bill, S. 2128, the Prevent Health Care Fraud Act of 2009. As the Senate debates the health reform bill in December, AAHomecare will alert you about any opportunities to improve the bill through amendments.

Save Homecare: Petition Aims for 1,000 Signatures by Year End
In honor of National Homecare Month, the American Association for Homecare has launched an online petition to Save Homecare. This petition recognizes the work of thousands of dedicated professionals who provide cost-effective and consumer-preferred homecare. It also draws attention to the current and planned regulations which threaten homecare quality and availability.

AAHomecare urges homecare patients, their families, and care providers to speak up for homecare and call or email their members of Congress and ask them to “Please stop cuts to homecare.” Families, patients, and stakeholders can also sign the online petition to Save Homecare. The completed petition will be sent to Congress.

Sign the petition and send it to 10 friends. Encourage them to sign and do the same. Together we can reach 1,000 signatures by year’s end. As of November 23, the petition is already one-third of the way to the 1,000 mark.

Thanks to home medical equipment and service providers, millions of seniors and people with disabilities will share Thanksgiving and other holidays with their families in the comfort of their homes. Families, patients, and the media can learn more about how to save homecare by visitingwww.aahomecare.org/athome.

AAHomecare also encourages the homecare community to send the National Homecare Month press release to your local media. This release is available on the homepage of the national association’s website, www.aahomecare.org. Add your logo and spread the word about the benefits of homecare. For assistance, please contact Tilly Gambill at tillyg@aahomecare.org.

AAHomecare Asks CMS to Delay PECOS and Fix the Enrollment Process
Calling attention to the slow pace of physician enrollment in the Provider Enrollment, Chain and Ownership System (PECOS), last week AAHomecare urged the Centers for Medicare and Medicaid Services to immediately delay the implementation of new rules surrounding front-end rejection of claims for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) based on ordering/referring physician enrollment in PECOS. The letter to Acting CMS Administrator Charlene Frizzera states, “We believe that unless CMS immediately delays the effective date when DMEPOS claims will be rejected because the referring physician is not enrolled with PECOS, patient access to care and disruptions in provider payments will inevitably occur.”

The letter includes the following recommendations:

“Due to the numerous outstanding concerns from DMEPOS suppliers, physician organizations, and other interested parties, AAHomecare requests that CMS:

1. Indefinitely suspend implementation of Phase 2 of the edits for ordering/referring providers in DMEPOS claims to avoid unnecessary claims denials for legitimate services being provided to Medicare beneficiaries.

2. Delay implementation of the Phase 2 edits and claims rejections for a minimum of six months. Provisions in House and Senate health reform legislations would require physicians who order/refer DMEPOS and home health services to be enrolled in Medicare with a July 1, 2010 implementation date. CMS should follow Congressional intent and delay the Medicare-enrolled physician requirement for DMEPOS services until a sufficient period of time after any enactment of a health insurance reform bill that contains the provision referenced above.

3. Develop and publish a corrective action plan that outlines how the Agency intends to have physicians enroll with PECOS.

4. Release the list of physicians enrolled in the PECOS database to the DMEPOS community to allow suppliers to have sufficient time to review, analyze, offer recommendations to CMS, and program their billing systems to accommodate the applicable information accordingly.”

Ask Wheelchair Consumers to Participate in Important Survey by Nov. 30
An important survey of wheelchair users is being conducted by National Spinal Cord Injury Association in partnership with United Spinal Association, Paralyzed Veterans of America, National Multiple Sclerosis Society, The National Council on Independent Living, United Cerebral Palsy Association, Muscular Dystrophy Association, and The ALS Association. The survey, which can be accessed at the link below, is designed to help these organizations understand and document the user’s most recent wheelchair selection and purchase experience. See: www.spinalcord.org/survey.

The initiative has also sought and accepted input from respected clinicians and from members of HME groups including American Association for Homecare (AAHomecare) and the National Coalition for Assistive and Rehab Technology (NCART).

“What we learn will help us advocate most accurately and effectively on behalf of all wheelchair consumers so that they receive properly fitted wheelchairs, including all necessary accessories and related services to fully participate in an active, healthy, community lifestyle,” stated a press release published by the National Spinal Cord Injury Association.

The group plans to present this information to policymakers on Capitol Hill and at CMS to support efforts to improve coverage and payment of custom-fitted wheelchairs and accessories and required services.

Contact Your Local AARP Office to Protest Misleading AARP Bulletin Article
In its November 2009 issue, the AARP Bulletin published a highly misleading article about HMEs that provide wheelchairs in Medicare. The article states that the difference between the acquisition cost and the average reimbursement for a wheelchair is a “threat to Medicare.” The article also confuses price-setting issues such as competitive bidding with anti-fraud measures. See article at the following link and see AAHomecare’s online response to the AARP below:

http://bulletin.aarp.org/opinions/fromtheeditor/articles/from_the_editor_the_case_of_the_expensive_wheelchair.comments.0.html#commentHeading

AAHomecare Response:
This misleading article incorrectly assumes that the only cost of providing a wheelchair in the home of a person with disabilities is the acquisition cost. The HHS Office of Inspector General (OIG) study cited notes that a number of services are essential and required: delivery, set up, fitting, maintenance, etc. OIG notes in the same report that it did not account for the cost of providing these required services.

AARP claims that efforts to address the excess [in Medicare] have been stymied, citing influence from the medical equipment lobby. In fact, reimbursement rates for durable medical equipment, including wheelchairs, were cut substantially in the Medicare Modernization Act of 2003 and in the Medicare Improvements for Patients and Providers Act of 2008 and rates have been subject to a freeze for the last five years.

The article implies that the medical equipment sector killed the competitive bidding program. It did not. Congress merely delayed it last year because, among other problems, the program was designed to put more than 80 percent of the home medical providers (the competitors) out of business, even if they agreed to new, lower, competitive bid rates. And Congress required that this sector pay for every dime that the bid program had been projected to save, via the 9.5 percent cut effective in January 2009.

A year ago the American Association for Homecare, which represents providers of home medical equipment, proposed a 13-point anti-fraud program. See www.aahomecare.org/stopfraud. That proposal recommends real-time claims audits, more site inspections, tougher penalties, and more resources for federal fraud-fighters.

Legitimate wheelchair providers in this sector suffer when policymakers and media misrepresent facts and smear this entire sector. Home medical equipment providers deliver cost-effective care that helps Americans remain independent and safe at home.