Home Health & Hospice Week

You should add a few steps to your physician verification process -- but that won't guarantee your claims are safe from take-backs down the road. Home care industry representatives were full of questions regarding PECOS enrollment requirements for referring physicians at the July 7 Open Door Forum for home care providers. That's because the mandate for referring physicians to be enrolled in Medicare's Provider Enrollment, Change and Ownership System took effect July 6.

The Centers for Medicare & Medicaid

Services issued a notice saying it wouldn't yet implement systematic edits that automatically reject claims lacking PECOS-enrolled physicians' National Provider Identifier numbers. But in the notice, CMS didn't rule out future recoupments for such claims (see Eli's HCW, Vol. XIX, No. 25, p. 194).

CMS reinforced that uncertainty during the call that drew more than 700 participants. "I understand what you would like me to say," CMS's Jim Bossenmeyer told Walt Gorski from the American Asso-ciation for Homecare. "But I cannot give you that answer today." Gorski was joined by Mary St. Pierre of the National Association for Home Care & Hospice and Bruce Rodman of the National Home Infusion Association in pressing CMS for more specifics on the PECOS requirement.

"I want to be absolutely certain I understand what home health agencies and DME suppliers are required to do in relationship to enrolled physicians," St. Pierre told CMS.

"Everybody is primarily concerned about ... the potential of recoupment in a future audit," Rodman said. "If ... a ZPIC or RAC audit occurs in 2012 and they look and see the effective date of the [PECOS rule] and see that the referring physician is not enrolled in PECOS," what then? Gorski asked.

CMS can't give any guarantees, Bossenmeyer said. But CMS does encourage home care providers to take these steps:

• Check to see whether your referring physician is enrolled in PECOS. CMS's new ZIP file containing the CSV file should help make that easier, Bossenmeyer noted (for instructions on  using the file, see Eli's HCW, Vol. XIX, No. 25, p. 195). CMS also has added a file for physicians whose PECOS enrollment is pending. That file contains about 26,000 physicians, Bossenmeyer said. Adding the pending list is a "nice touch," judges Lynn Olson with Astrid Medical Services in Corpus Christi, Texas.

Pitfall: You should be aware that a pending file won't always be finalized. CMS could reject it, Bossenmeyer reminded listeners.

• Submit all claims with the physician's legal name and NPI. Whether your ordering physician is in PECOS or not, you need to submit a claim with the doc's legal name and Type 1 NPI, Bossenmeyer instructed. Be sure you use the physician's individual NPI, not the one for her practice.

Tip: The physician's legal name must match the one in his PECOS record. A number of physicians have only their first initials, not their entire first names, in PECOS, noted an HHA caller from Florida. PECOS is supposed to contain the physician's first name as it is kept by the Social Security Administration, Bossenmeyer said. If it's listed in the PECOS file with a first initial, then it should match that format on your claim, he advised.

• Check state licensure, OIG exclusions. If your ordering physician isn't enrolled in PECOS yet, you should find other ways to verify her eligibility to order Medicare services, Bossenmeyer said. That includes checking state licensure and that the physician isn't excluded by the HHS Office of Inspector General, he suggested.

"If they do not have a state license and you do some type of an onsite review afterwards, then we will be looking at that particular issue," Bossenmeyer promised.

But checking these things won't necessarily keep your claims safe. "That is one factor that you will be looking at," Bossenmeyer said.

• Encourage physicians to enroll. CMS is keeping up its efforts to encourage physicians to enroll in PECOS. But in the end, physicians' Medicare reimbursement is not affected if they don't.

"We're doing everything possible to get the doctors to enroll," a supplier from Minnesota said in the forum. "But we can't force them to get it done." If your ordering physicians aren't in PECOS, you "may want to contact them and let them know that they need to take steps to go ahead and continue the process of getting their enrollment information updated with Medicare," Bossenmeyer suggested.

Gorski asked if suppliers should have patients without PECOS-enrolled physicians sign an advance beneficiary notice (ABN) or pay cash. Bossenmeyer ducked the question, saying that most physicians are enrolled in PECOS and reiterating the guidance to include the physician information on the claim and check state licensure and OIG exclusion status.

• Document, document, document. Providers should maintain documentation for all referrals they receive, Bossenmeyer said.

Timeline: CMS is still deliberating on the start date for the edits automatically rejecting HHA and DME claims without PECOS-enrolled physicians. Suppliers already receive informational edits on the topic and HHAs are scheduled to start receiving the informational edits in October. For both types of providers, edits rejecting claims are currently slated for January, although that timeline might be moved up, CMS has hinted.

Even if auditors never go back and recoup monies from this transitional time period, home care providers could be in for a world of hurt once the PECOS physician edits start in the new year -- or earlier.

"Our concern is about the recoupment that will happen as of Jan. 4," the Minnesota supplier said. CMS is still deliberating on other points of the policy as well, including physicians -- such as those working for the Veterans Administration -- who are not enrolled in Medicare, Bossenmeyer said.

Watch for: CMS will try to issue more PECOS clarification soon, Bossenmeyer pledged.

Note: More information on PECOS, including the lists of PECOS-enrolled or ��"pending physicians, is at www.cms.gov/MedicareProviderSupEnroll/06_MedicareOrderingandReferring.asp.