Home Health & Hospice Week

Will you take the physician’s word for it?

Just like saying “the check is in the mail,” it will be easy for physicians to circumvent your PECOS edit precautions by assuring you they’ve applied for enrollment in the system. Don’t let false promises torpedo your reimbursement.

One strategy: The most conservative approach will be to decline to take referrals unless the referring physician is actually in the Centers for Medicare & Medicaid Services’ approved PECOS file. “Just having made an application is a day late and a dollar short,” insists financial expert Pat Laff with Laff Associates in Hilton Head Island, S.C.

However, while gray areas still remain, it appears that home health agencies will be able to secure payment for their claims if the physician actually was enrolled in Medicare at the patient’s start of care and had a PECOS enrollment application pending. Most experts agree that the PECOS enrollment approval date has to be before the patient’s SOC once CMS approves it.

You should work closely with a physician’s staff to figure out when the doc submitted her PECOS application and, thus, when the approval date will be once CMS greenlights the record, recommends M. Aaron Little with BKD in Springfield, Mo.

The problem: HHAs will risk alienating a referral source if they say “no” to a referral while the doc’s PECOS application is pending, notes Tom Boyd with Boyd & Nicholas in Rohnert Park, Calif.

But a pending application doesn’t mean the doc will achieve enrollment for sure, points out Little. “If … a physician doesn’t complete the enrollment correctly then it could delay both the date of enrollment and date of approval, which could become a problem for providers,” Little says.

Hold Claims For Pending Docs

If you decide to risk it and furnish services to a patient whose doc had a pending PECOS record, don’t submit the final claim yet. “Hold the claim until the enrollment is processed in PECOS to avoid a denial on the claim,” counsels Frost Ruttenberg & Rothblatt on its website. But remember, “the enrollment date must still precede the dates of service.”

If you are just now doing your research and turning up docs without PECOS records, they can still apply for enrollment and you’ll be clear for the edits, assuming the doc’s record is approved. But you’ll have to cool your heels — and your claims — while you’re waiting for the record to process. CMS is taking 45 to 60 days to complete PECOS applications, FR&R notes.