BALTIMORE — In response to a nationwide uproar in the physician, pharmacy and home medical equipment communities over a July 6 compliance date for physician/prescriber enrollment in PECOS, CMS issued a statement June 30 saying it was reviewing the process.
"CMS will, for the time being, not implement changes 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," the agency said.
CMS' announcement that it is working to address the concerns of the various stakeholders didn't change anything, those in the HME sector said.
Under the Affordable Care Act, only Medicare-enrolled physicians or eligible professionals may certify or order for Medicare beneficiaries such services as home health, home medical equipment, prosthetics, orthotics and supplies. To be considered enrolled, they must have records in the Internet-based Provider Enrollment, Chain and Ownership System. The initial deadline for enrollment and implementation was Jan. 3, 2011, but CMS said in order to be compliant with the new health reform law, it had to push the enrollment deadline up to July 6.
The statement did not address the key sticking point: That providers submitting claims in good faith from July 6 to Jan. 3 could be required to return Medicare payments if the certifying or ordering physician was not enrolled in PECOS.
"They just told us what we already know. [The statement] basically restates the current state of play, which is that the effective date is July 6 and the implementation date is Jan. 3," said John Shirvinsky, executive director of the Pennsylvania Association of Medical Suppliers. "That has never been in question. What has been in question is the [possibility of recoupment] … Every claim that has been honored between July 6 and Jan. 3 can be recouped if the auditors decide that is the thing to do.
"There is a difference between getting paid and staying paid."
Wayne Stanfield of the National Association of Independent Medical Equipment Suppliers agreed.
"It says the same thing, but implies that they will not enforce it in a strange way by saying they will use a contingency plan to assure only valid physicians are used," he said. "I'm not at all comfortable with this, but it is better than nothing."
AAHomecare Wants Clarification
The American Association for Homecare said it was pleased at CMS' announcement, but added "the association remains extremely concerned, based on the extent of auditing activity that HME providers are now confronting, that HME providers may still be vulnerable to future recoupment activities from post-payment audits. We are working with CMS staff to seek additional clarification and guidance on this issue."
HME providers, physicians and others have complained in vast numbers to CMS about the recoupment issue as well as the deadline.
AAHomecare sent a letter to CMS last week setting out its concerns with the PECOS edits on HME claims. Noting that "patient access to care and disruptions in provider payments will inevitably occur unless CMS delays the implementation date," the organization recommended that CMS:
- Adhere to its original Jan. 3, 2011, deadline;
- Publicize, in December 2010, the percentage of physicians and eligible professionals enrolled in PECOS and delay the implementation date unless that figure is greater than 5 percent of the number of prescribing clinicians nationwide;
- Grandfather Medicare claims for DMEPOS items and services billed on a monthly basis, such as capped rental items, and for those items that Medicare continues to pay a maintenance and service fee;
- Instruct contractors that claims that are not PECOS compliant not be subject to recoupment based solely on the PECOS-related issues between July 1, 2010, and the implementation date;
- Develop a searchable database that can be imported into a supplier's computer system to determine if prescribing clinicians are enrolled in PECOS.
To view the full letter, see the AAHomecare website.
Pharmacists, Physicians Worried, Too
Complaints have also arisen in other health care camps. NAIMES reported that the National Association for Homecare & Hospice has generated nearly 1,000 calls to Congress about PECOS over the past few days.
The National Association of Chain Drug Stores has also been in discussion with congressional leaders about the issue and is submitting comments to CMS. An NACDS statement noted its members "are already confronting 30 percent rejection rates on their Medicare Part B claims due to the fact that providers are either unaware or not properly enrolled in PECOS."
At its meeting in Chicago this week, the American Medical Association called on CMS "to return the deadline for enrolling in [PECOS] to Jan. 3, 2011."
Meanwhile, HME providers have been working to get their referral physicians enrolled in PECOS, a job CMS has said is essentially theirs.
Shirvinsky said CMS is not doing much to get physicians enrolled.
"They have sent out, to my knowledge, two notices to physicians. That compares with the three notices a week for two-and-a-half years about complying with the [National Provider Identification] process," he said.
In any case, it would be tough to get every physician enrolled by July 6. The system is reportedly backlogged, with a three- to six-month waiting period to obtain PECOS registration, Shirvinsky said.
CMS has said that PECOS warnings have dropped from 6 million per month to 3 million, "but 3 million is still a very large number," Shirvinsky said.
Providers can take some steps to protect themselves, according to NAIMES. The organization suggested that providers say no to all referral requests from physicians not registered and explain the risk of having payments taken back; consider calling patients with capped rental, long-term oxygen and the like whose physician is not registered and changing their claims to non-assigned; and encourage Medicare patients to contact their legislators and alert them to the difficulties with the current PECOS rule.
"Have them tell Congress that the physician must be held accountable, not the provider taking the referral," NAIMES urged.
Read the full CMS announcement.
