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.

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.

“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.