Home Health & Hospice Week

The feds' stance on your referring physicians' PECOS enrollment is far from clear, but home health agencies probably aren't in danger of losing reimbursement for up to 40 percent of their patients.

At least that's what industry experts hope after receiving more clarifying information from the Centers for Medicare & Medicaid Services.

July 6 was the implementation date for the requirement mandating that referring physicians listed on certain Medicare claims -- including those for home health agencies and durable medical equipment suppliers -- be enrolled in the Medicare Provider Enrollment Chain and Ownership System (PECOS). Shortly before that date, CMS issued a cryptic notice saying it was sticking with the July 6 deadline, but not implementing "automatic" rejections of claims without PECOS-enrolled physicians in the ordering/referring physician field (see Eli's HCW, Vol. XIX, No. 24, p. 186).

"Due to the vague language in the PECOS notice, [the National Association for Home Care & Hospice] requested additional clarification from CMS regarding how to interpret enrolled physician requirements," NAHC says in its member newsletter.

The response NAHC received from the CMS Acting Administrator isn't crystal clear, but it is encouraging, the trade group says. CMS is having "system capacity issues in PECOS that we are  working to resolve," CMS says. "Folks are still required to submit their information per statutory deadlines and we will continue to monitor appropriate use."

But: "Until we work out the issues with PECOS, we will continue to pay claims as we do today," the response to NAHC says. CMS "will not automatically reject claims that do not include a PECOS enrollment number."

Further, "we will not look to the PECOS system as our only tool for determining if physicians are participating in the program," the response says. NAHC interprets this response to mean "that enrollment in PECOS will not be required at this time because of the 'system capacity issues in PECOS,'" the trade group concludes.

In the July 7 Open Door Forum, CMS talked about a delay to the PECOS deadline. But "it was still unclear whether ... providers could be subject to recoupment if referring providers are not in the PECOS system," says the American Association for Homecare. AAHomecare "continues to press CMS for clear and unambiguous guidance," the trade group says.

What to do now: CMS still expects physicians to enroll in PECOS, however, NAHC points out. Therefore, you should be asking your physicians whom you can't find in PECOS if they are enrolled or in the process of enrolling. (Document their response in the record.) If not, assist them in enrolling before you accept their patient for care, NAHC counsels.

Good news: CMS has begun updating its list of ordering and referring physicians enrolled in PECOS twice a week instead of once a month, NAHC reports.