By: Andrea Stark, DMEPOS Consultant

The July 6th PECOS enrollment deadline established in CMS’ May 5th interim final rule created quite a stir among suppliers in the DME community, and left many looking for direction on what to do in the muddy water of PECOS validations. While CMS has confirmed that PECOS rejections of DME claims will not begin until January 3, 2011, they have not issued any specific statements regarding the potential for retroactive recoupments.

The goal of this article is to help you make intelligent decisions about the impending consequences of various options available to you. While we are often presented with black and white scenarios that give us only two options, neither of which are desirable, in the case of PECOS I don’t see it so starkly. Instead, I believe there is a middle of the road approach that can be more suitable to those suppliers worried about the possibility of retroactive recoupments.

After taking a close look at specific language in the Patient Protection and Affordable Care Act (PPACA or ACA) in conjunction with the press release issued by CMS on June 30th, it is my professional opinion that continuing to accept orders from physicians who are not yet in PECOS (but are otherwise legitimate, Medicare enrolled providers) is an acceptable risk, provided you’ve done your homework.

Sec. 6405 of the ACA specifically requires all physicians who order items or services under Medicare “to be Medicare enrolled physicians or other eligible professionals.” In terms of DME, the ACA requires that certifications and written orders only be made by “enrolled physicians” effective July 1, 2010, and that the ordering physician’s name and NPI be included on all claims. The ACA does NOT specifically reference the PECOS database. However, CMS is choosing to use this system as a tool to verify physician enrollment and maintain compliance with ACA requirements.

On May 5th CMS issued an interim final rule mandating that physicians who order DMEPOS have an approved enrollment record in PECOS effective July 6, 2010. This enrollment requirement was also extended to physicians who order home health services and other covered Part B services (laboratories, imaging suppliers, specialists).

One June 30th CMS issued a press release to reiterate and clarify that PECOS rejections will not begin until January 3, 2011, specifically stating that:

“Many physicians and other providers and suppliers have continued to make good faith efforts to comply with the requirements of the law and regulation. These efforts will be a significant factor in determining the procedures and processes that will be incorporated in the final rule.”

“Additionally, though CMS is taking a more deliberative approach to using the PECOS enrollment system, the agency will employ a contingency plan to meet the ACA requirement that written orders and certifications are only issued by eligible professionals effective July 1.”

What this says to me, is that CMS understands suppliers and physicians are making “good faith efforts” to comply with the law. Additionally, CMS is admitting that PECOS is not ready to be relied upon solely, and they are resorting to a “contingency plan” to stay in compliance with ACA requirements. This most likely means they will reference the Part B contractor’s enrollment database to verify a physician’s enrollment in Medicare while the PECOS database is brought up to speed.

Based on this information and my experience in the field, it is my belief that unless there is a true issue with improper payments, claims submitted for legitimate referral sources are not likely to be retroactively recouped. At this point, those physicians resulting in PECOS warning messages are predominantly well established physicians who have been practicing for 10+ years and are otherwise legitimate, Medicare enrolled providers. As long as you’ve done your homework and are able to verify that the physician is a legitimate provider with the proper credentials to order DMEPOS, then it should present a minimal risk to continue accepting orders from that physician.

While there is always the potential that a claim could be audited or recouped down the road, whether or not to accept an order ultimately comes down to assessing the risks. Is the risk of alienating an established referral source (and permanently losing those referrals and revenue) greater to your company than the potential that you may be audited down the road?

At this time, the best thing you can do is establish a risk policy for your company. Have a set of guidelines in place to help you decide whether you will ultimately continue taking orders from individual physicians not yet enrolled in PECOS. At a minimum, you should work to ensure that each referral source:

1. Understands the PECOS enrollment requirement and has recently enrolled or plans to enroll in the system (sooner rather than later).

2. Is licensed to practice in the state.

3. Is enrolled in the Medicare program and is otherwise eligible to order/refer DMEPOS (has the appropriate credentials and has a Medicare provider number).

Bottom line, you must do your homework and make sure you can validate that the referral source is a legitimate provider prior to accepting an order. By taking these steps, your claims will be in compliance with federal ACA requirements that ordering physicians be enrolled in Medicare by July 1, 2010.

It is my expectation that CMS will modify the interim final rule before publishing the final version. The comments submitted to CMS have already seen press coverage in their June 30 release on the matter (even CMS acknowledges that they cannot rely on PECOS exclusively right now). To further support this position, neither the CEDI contractor nor the DME MACs have received any indication that the January 3, 2011 rejection date is going to change.

Have questions about this content? Andrea Stark offers on-call consulting services for DMEPOS suppliers. Visit our Services page to learn more.

A digital recording of Andrea’s 7/29/10  ”Have PECOS Questions? Get Straight Answers!” webinar is also available for purchase on our Products page.

Some suppliers may be receiving rejection warnings for physicians otherwise identified as enrolled in PECOS. MiraVista recently learned that CEDI’s list of PECOS enrolled physicians is incomplete, which may result in the incorrect firing of warning messages for enrolled physicians. CEDI is aware of the issue and is working to update their records as quickly as possible.

Bottom line, if you are able to match the physician’s NPI and exact spelling of their first and last name in CMS’ list of PECOS enrolled physicians, then they should not result in rejections beginning January 3, 2011. CMS last updated the .csv ordering/referring PECOS file on July 15, 2010.

• Confused about whether your payments will be recouped when PECOS edits are implemented?
• Concerned about billing claims where the ordering physician isn’t listed as enrolled in PECOS yet?
• Worried about the impact PECOS rejections will have on your business?

Due to the increasing number of inquiries MiraVista is receiving regarding the July 6 PECOS physician enrollment deadline and January 3, 2011 rejection implementation date, we have decided to hold a timely PECOS webinar. The majority of the webinar will be held as an open forum for suppliers to ask and receive answers to their PECOS questions directly from DME consultant Andrea Stark.

If you’re ready to get straight answers to your PECOS questions, then this webinar is for you!

We will start with a brief presentation explaining how the PECOS edits will be implemented and covering the latest PECOS updates. The webinar will conclude with an extensive interactive question and answer session.

The webinar will be held on July 29, 2020 at 2:00pm EST. Registration is just $99 per conference line.

Don’t miss out on the chance to get your questions answered! Click Here to be taken to our Seminars/Webinars registration page.

A new PECOS list posted by CMS eliminates almost all of the guesswork when it comes to checking on the status of enrolling physicians. As of July 12, 2010, suppliers can now check to see whether their physicians’ applications are pending contractor review.

CMS has posted two new lists to the Medicare Provider and Supplier Enrollment section of their website: 

• Initial Physician Applications Pending Contractor Review [ZIP, 719KB]
• Initial Non Physician Applications Pending Contractor Review [ZIP, 91KB] 

ClaraVista’s Maureen Bacon was able to confirm with CMS that the lists are exactly as the titles imply; they include the names and NPIs of those physicians and non-physician practitioners whose PECOS applications have been submitted for review.

The publication of these lists follows a recent series of positive breaks for DME suppliers, who are now able to easily identify PECOS enrolled physicians via a frequently updated .csv data file (for more information see CMS Updates CSV PECOS List More Frequently; Twice per Week). Rather than calling a physician’s office directly, suppliers now have an alternate resource to confirm whether a physician has at least submitted their PECOS or CMS-855 enrollment application.

As applications are processed, physicians will be removed from the pending review list and added to the Medicare Ordering and Referring File, which was also updated on July 12, 2010. We expect the two review lists will be updated with the enrollment file simultaneously. As of late, the .csv file is being updated twice per week. You may download the latest version of all three lists by visiting:

http://www.cms.gov/MedicareProviderSupEnroll/06_MedicareOrderingandReferring.asp.

We recommend suppliers note the date a physician first appears on the pending review list. If a particular physician’s name remains on the list for an extended period of time, it may be a sign that their Certification Statement has not yet been submitted. At the end of the online enrollment process, physicians are required to print, sign and mail in a paper Certification Statement, and contractors will not process a PECOS application until that statement is received. For physicians whose applications linger on as pending, a phone call may be warranted to confirm whether their Certification Statement was mailed in.

With the establishment of the July 6^th physician enrollment deadline, a recent surge in applications may have contributed to processing back-logs for some contractors.

Recently, MiraVista was contacted by a concerned supplier who found differences between the .csv and .pdf PECOS files they downloaded from CMS. The number of physicians in the .csv version didn’t match those in the .pdf. Naturally, we wanted to know why. So we rolled up our sleeves and did a little digging.

On June 29^th, Maureen Bacon, the controller for our sister billing company ClaraVista, went back to CMS’ website and downloaded the zipped .csv file. As it turns out, CMS modified the file after we first informed you about it on the 24^th. Here’s what we found: 

• The original file that was made available on June 24^th was named OrderReferringJune2010.csv. It was 18.0MB in size, and contained 687,819 lines. (Note: This is the one we first wrote about and is likely the one you downloaded.)
• The file that is now on the site was created by CMS on June 25^th at 8:41am and is named OrderReferring_June2010v2.csv. It is 18.1 MB in size and contains 719,024 lines.

Based on these findings, Bacon sent an inquiry to CMS asking if the .csv file, which now contains an additional 31,205 lines, would continue to be updated more frequently. CMS confirmed that the file will indeed be updated on a regular basis.

“If we don’t have any issues CMS plans to put a new file up twice per week,” wrote one CMS official.

Long story short, it looks like the .csv PECOS file will be updated more frequently than the monthly updates originally scheduled for the .pdf version. To our knowledge, CMS is not yet releasing announcements to let suppliers know each time a new file is posted.

The new .csv Zip file may be downloaded the same way as the previous version, by visiting:

http://www.cms.gov/MedicareProviderSupEnroll/06_MedicareOrderingandReferring.asp.

Please be sure to bookmark this site, www.miravistallc.com/blog, and check back regularly for future PECOS news alerts and announcements!

“All I had to do was ask. After a bit of back and forth, they put the PECOS physician list in a .csv format for everyone to download.” – Maureen Bacon, Controller, ClaraVista.

That’s right. Problem solved! CMS has finally uploaded a list of PECOS enrolled physicians in a useable .csv format. Unlike the previous .pdf version, the .csv file will open in Excel or Notepad and can be easily imported into Access. This allows users to quickly sort, filter and search the data with a click of the mouse.

“This is a huge breakthrough,” said Bacon, “We tried to convert the massive .pdf to a .csv file on our own, but even with dual core processors and a T3 internet connection, it proved to be painfully slow and my computer system all but grinded to a halt during the process.”

Bacon said the final straw came after she converted 3,700 of the 13-some-odd-thousand .pdf pages, and then lost it all to a system error.

“I waited 3 hours to get less than a third of the way through and then lost everything,” said Bacon. “I knew I wasn’t the only one having this problem, and I wanted to find a solution that would help us, our billing clients and anyone else who needed a better way to search for physicians in PECOS.”

Thanks to Google and a bit of ingenuity, Bacon located an early transmittal issued by CMS that parsed out responsibilities for implementing the PECOS edits.

“I found a release that contained the names and e-mail address of two of the people put in charge of creating the PECOS file,” said Bacon. “I sent them an e-mail explaining the problems I was having with the .pdf and asked them if they could convert the file into a more user friendly spreadsheet.”

Believe it or not, Bacon received a response just thirty minutes later.

Initially, Bacon was advised to independently convert the .pdf to text or use the search function to look up the physician’s NPI.

“It was clear to me that they didn’t fully understand how long it takes to search 13,000 pages for hundreds of physicians in a .pdf file,” said Bacon. “So I gave them an NPI from the last page and asked them to start at page one and search for it; just so they could see how long it takes for themselves.”

And it looks like that did the trick!

Less than 24 hours after her last correspondence with CMS officials, a new Zip file was posted for download at:

http://www.cms.gov/MedicareProviderSupEnroll/06_MedicareOrderingandReferring.asp.

The Zip contains a .csv version of the PECOS file, which lists all 687,819 physicians currently enrolled in the system.

But Bacon doesn’t credit herself alone for the breakthrough.

“I didn’t do this one on my own,” said Bacon. “There have been many people before me, including Medicare contractors and industry organizations, who have asked CMS to put the .pdf in a better format. I guess I just happened to contact the right people at the right time.”

Lucky us.

We’d like to offer a special thanks to CMS for listening to our concerns and being so responsive on this issue.

Suppliers and physicians who owe back-taxes to the IRS may want to get their accounts squared away as soon as possible. According to a recent piece of legislation passed by the Senate, suppliers who owe on their taxes are seen as more likely to commit Medicare fraud and abuse than those who don’t and could become subject to additional scrutiny during enrollment.

The legislation, entitled the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010 (H.R. 3962), would require the IRS to inform the Department of Health and Human Services (HHS) about “delinquent tax debts” held by physicians and suppliers who apply to enroll or reenroll in the Medicare program. Upon request, the IRS must confirm the identity of the party in question and provide HHS with information on the amount of tax owed by the individual, along with the year to which the debt applies.

The bill would grant the Secretary the authority to use this tax information when determining whether a physician or supplier is eligible to enroll or reenroll in the Medicare program. Suppliers and physicians with delinquent tax debts – defined as debt for which a lien has been issued, or a collection hearing is in process, and no payment arrangements have been made - may be subjected to periods of enhanced oversight or denied enrollment entirely. The Secretary is also granted the authority to adjust Medicare payments to suppliers and physicians based on the amount of delinquent tax owed.

As you may recall, H.R. 3962 was once known as the Affordable Health Care for America Act and was originally passed in the House as their version of healthcare reform. Because the U.S. Constitution requires all revenue-generating bills to originate in the House, the Senate took H.R. 3962 (a House originated bill), completely stripped it of all original content, renamed it, and is now using it as a medium for the Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010.

Before this bill may become law, the House and Senate must marry their two versions of the bill together and reconcile their differences. Since this bill is completely unrelated to the original version, members of the House will likely vote to reject the bill entirely or accept it only on the condition that certain amendments are included. If amendments are made to the bill, it will once again go back to the Senate for approval.

It’s possible that Congressmen whose healthcare reform ideas were not included in the signed Patient Protection and Affordable Care Act (PPACA or H.R. 3590) may continue to fight for their inclusion in this bill, and we may see several unrelated amendments added to the bill in order to secure votes.

We will keep you apprised of any updates or changes to the bill’s status in our August issue of Vista Notes. You may also read the full text of the bill here:  http://thomas.loc.gov/cgi-bin/query/z?c111:H.R.3962.

When given the opporunity, we like to tinker with new ideas and get our creative juices flowing. Recently, our marketing department started to experiment with creating short clips to help advertise what we do. We thought these turned out pretty neat and wanted to share them with you. Enjoy!

Can’t see this clip? Visit: http://www.youtube.com/user/MiraVistaLLC#p/a/u/1/lVpDOrNee6M.

Can’t see this clip? Visit: http://www.youtube.com/user/MiraVistaLLC#p/a/u/0/9DMnDMejapI.

All currently enrolled DMEPOS providers are required to become accredited by September 30, 2009, and newly enrolling providers must become accredited prior to submitting their application to the NSC.

During this episode of VistaCast, president of ACHC Tom Cesar gives new providers an inside perspective on the accreditation process, and DME consultant Andrea Stark discusses what providers need to know should they opt not to become accredited.

Click on the play button to watch this VistaCast!

Trouble viewing this VistaCast? Watch it on YouTube here: http://www.youtube.com/watch?v=VwQLhzgjFEU.

MiraVista traveled all the way from Columbia, SC to Las Vegas, NV to attend this year’s Spring Medtrade.

While there, Medicare consultant Andrea Stark held two courses - one regarding DME respiratory regulations and the other on Medicare billing. In between classes, we had an opportunity to walk the exhibit floor and mingle with other members of the DME industry.

Suppliers attending the event were able to get glimpses of the latest DMEPOS products, as well as educate themselves about recent Medicare changes.

Watch this VistaCast to see highlights of the Spring 2009 Medtrade event.

Trouble viewing this VistaCast? Watch it on YouTube here: http://www.youtube.com/watch?v=E9pZpLJ5v-U.