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.