Be sure you’re on top of these costly edits before they hit May 1.
If you aren’t checking your referring docs against the latest Ordering/Referring report from Medicare, you’re asking for appeals headaches.
Why? The second phase of so-called PECOS edits are hitting in less than two weeks. Under the edits, your home health agency claims will deny if the ordering/referring physician isn’t enrolled in Medicare, doesn’t have a PECOS record, if the physician info (name and NPI) on your claim doesn’t match that PECOS record, or if the doc isn’t of a specialty eligible to refer.
"In Phase 2, if the ordering/referring pro-vider does not pass the edits, the claim will be de-nied," HHH Medicare Administrative Contractor NHIC emphasizes in a message to providers. "This means that the billing provider will not be paid for the items or services that were furnished based on the order or referral."
Home health agencies do seem to be paying attention to this development that could severely restrict their cash flow, however. When HHH MAC CGS analyzed claims from September to February, it found that about three-fourths of HHAs had filed claims during that period which would be denied by the new edits. In contract, HHH MAC Palmetto GBA found about 40 percent of HHAs filed claims that would fail the edits in January and February.
Good news: And while many agencies would fail the edits, the number of claims denied is modest. In Palmetto’s analysis, only 2.4 percent of the 2.3 million claims in that time period would have denied. In CGS’s analysis, Medicare would not have paid about 4 percent of claims under the edit.
Take These Steps To Head Off Denials
But those stats won’t be much comfort if it’s your claims being denied due to the PECOS edits. You can head off such denials by making sure all your docs are in the Ordering/Referring report on the Centers for Medicare & Medicaid Servi-ces’ website.
If unenrolled docs slip through or if the physician info you enter doesn’t exactly match what’s in the PECOS record, you’ll see denials with two reason codes: 37236 or 37237, Palmetto notes in a new fact sheet about the edits. Medicare also will deny claims if the doc isn’t of a specialty approved to refer to home health.
When the physician isn’t enrolled in Medicare and PECOS, you are just out the money. But if the physician data you entered doesn’t match the PECOS record, you can pursue your rightful reimbursement — at a cost. "If you have a claim denied due to the Ordering/Referring provider edits, you must file an appeal," Palmetto reminds agencies in a message to providers. "An adjustment cannot be submitted."
And don’t expect to be able to recover money from beneficiaries if their docs have failed to enroll in PECOS. "Billing Providers should be aware that claims that are denied because they failed the Ordering/Referring Provider would not expose the Medicare beneficiary to liability," Palmetto says in the fact sheet. "Therefore, an Advance Benefici-ary Notice is not appropriate."
Acquaint Reluctant Docs With Opt-Out Status
Tip: You can’t give docs who work for the VA or other entities a pass. If the physician isn’t enrolled in Medicare and PECOS, you won’t get paid. "This includes interns, residents, fellows, and those who are employed by the Department of Vet-erans Affairs (DVA), the Department of Defense (DoD), or the Public Health Service (PHS) who order or refer items or services for Medicare beneficiaries," Palmetto explains.
You can remind physicians that they can officially opt out of Medicare and still get the enrollment info you require for payment. "You may order items or services for Medicare beneficiaries by submitting an opt-out affidavit to Palmetto GBA," the MAC tells such providers in the fact sheet. "Your opt-out information must be current (an affidavit must be completed every 2 years, and the NPI is required on the affidavit)."
Don’t forget: You must use the physician’s individual NPI on the claim, not the one for his organization, Palmetto stresses.
Note: The fact sheet is at www.palmettogba.com/event/pgbaevent.nsf/vwAttach/96PMP57868/$File/ACT_Ordering_Referring_J11_Handout_4-17-2013.pdf or e-mail editor Rebecca Johnson at rebeccaj@eliresearch.com for a free copy — use "PECOS fact sheet" in the subject line.
