Home Health & Hospice Week

You'll risk non-payment and even False Claims Act liability if you submit claims without a PECOS-enrolled physician's NPI starting July 6. The Centers for Medicare & Medicaid Services' instructions on the new Medicare Provider  Enrollment Chain and Ownership System (PECOS) have been conflicting and vague. But it appears that home health agencies, durable medical equipment suppliers, and other Part B providers must include the referring physician's National Provider Identifier (NPI) on Medicare claims and the physician must have an approved record in the PECOS system.

If not: Claims that don't have a referring physician's NPI in the PECOS record by July 6 are not eligible for payment.

Where it gets confusing: CMS doesn't have the claims system edits ready for the new PECOS requirement. In an April transmittal, the agency said it planned to start informational PECOS edits for HHAs in October and edits that actually reject claims next January. But the requirement is in effect as of July 6 anyway, CMS's Jim Bossenmeyer said in the latest Open Door Forum for home care providers (see Eli's HCW, Vol. XIX, No. 21, p. 163).

Claims without valid PECOS NPIs will pay in the system without those edits. But providers will risk having those payments recouped if CMS applies edits retroactively, cautions the National  Association for Home Care & Hospice. This could be an issue that finally brings Recovery Audit Contractors into the HHA industry, NAHC says. And agencies could face False Claims Act violation charges if they submit claims without valid referring physician NPIs, adds the Texas Association for Home Care & Hospice in a member alert.

Late-breaking development: CMS issued a notice June 30 saying that it won't implement "automatic" rejections of claims that don't have a PECOS-enrolled physician's NPI listed. But the message doesn't directly address medical and other retroactive review.

Providers' "good faith efforts to comply with the requirements of the law and regulation ... will be a significant factor in determining the procedures and processes that will be incorporated in the final rule," CMS says in the notice.

Bottom line: "The regulation will be effective July 6, 2010," CMS reiterates in the message. Also, "the agency will employ a contingency plan to meet the ACA requirement that written orders and certifications are only issued by eligible professionals effective July 1," CMS says. "We are concerned that there still may be risks for payment recoupment," the National Association for Independent Medical Equipment Suppliers says of the notice.

CMS's conflicting information has left agencies confused, multiple HHAs tell Eli. And "it is such a short time period to implement the screening of physicians and notify patients and physicians," protests Bonnie Vos with Skiff Home Care in Newton, Iowa.

Many home health agencies are unaware of the new PECOS requirement altogether, believes consultant Tom Boyd with Boyd & Nicholas in Rohnert Park, Calif. This has reached "the crisis point of no return," NAIMES says.

Enforcing this requirement "is a quick and easy way to curtail services and save Medicare dollars," Boyd adds.

Difficulty using the PECOS system and file are compounding the problem. Physicians are having difficulty confirming or enrolling in PECOS, reports Serese Wiehardt with Howard County Home Health and Hospice in Fayette, Mo.

For example: One physician employee stayed on the PECOS system more than seven hours trying to check the doctor's enrollment status, but the system was so overloaded she couldn't complete the process, Wiehardt says.

Other physicians report receiving PECOS approval letters months ago, but still not being listed in CMS's file of PECOS-enrolled physicians on the website, Wiehardt relates.

CMS updates its PECOS file only every four to six weeks, NAHC notes. That makes it hard for providers to figure out whether their referring physicians are actually enrolled yet.

Confusion over NPIs could also trip up providers, warns Lynn Olson with Astrid Medical Services in Corpus Christi, Texas. HHAs have to use the physician's individual NPI, not the NPI for her practice or hospital, in the claim's referring/ordering physician field.

Many referring physicians and hospitals may think they are PECOS-ready if the hospital or practice is enrolled, but not the individual practitioner, Olson worries.

At least one technical problem has been resolved, NAIMES points out. CMS has posted the PECOS-enrolled physician file is a more userfriendly CSV format, which eliminates the lengthy PDF file search process providers were being forced to perform.