Home Health & Hospice Week

The number of your docs without a PECOS file may surprise you.

Home health agencies will find themselves in an awkward situation with referral sources come May 1 — one that could cut into their bottom line.

HHAs have just a few short weeks left until Medicare’s so-called PECOS edits enter phase two. In that phase, the edits will deny HHA claims when the physician listed on the claim doesn’t have a record in PECOS.

Background: Back in 2009, the Centers for Medicare & Medicaid Services implemented edits for home health agencies, durable medical equipment suppliers, and physicians detecting when claims contained an invalid ordering or referring provider. Under the edits, the ordering physician for HHA services must have a valid National Provider Identifier (NPI) number and be enrolled in Medi-care’s Internet-based Provider Enrollment, Chain, and Ownership System (PECOS).

But the first phase of edits has been informational only, so claims still pay even if the physician information is incorrect. In those cases, home care claims process with this message: N272 — Missing/incomplete/invalid other payer attending provider identifier.

CMS originally intended to implement phase 2 of the edits fairly quickly. But an outcry over PECOS enrollment problems from providers affected by the edits has delayed that phase — until now.

Make the Tough Calls

Now time has run out. “Providers must verify PECOS enrollment status prior to accepting referrals/orders from a physician,” urges consulting firm Frost Ruttenberg & Rothblatt on its website.

If the doc isn’t in PECOS, you’ll have to say “no” to accepting his referral, says Tom Boyd with Boyd & Nicholas in Rohnert Park, Calif.

HHAs “just can’t afford to provide care and not get paid for it,” maintains financial consultant Pat Laff with Laff Associates in Hilton Head Is-land, S.C.

Do this: Inform all your physicians now that in accordance with Medicare regulations, you won’t be able to accept referrals when physicians are not enrolled in PECOS, Laff advises.

Do Your Homework Now

You can head off these awkward situations by getting as many of your delinquent physicians to enroll in PECOS as possible before the deadline. And there may be more problem docs than you think.

 “Many agencies may be surprised at the number of physicians from whom they receive orders/referrals that don’t have an active enrollment in PECOS,” says billing expert M. Aaron Little with BKD in Springfield, Mo. “Most of our clients have at least one physician — if not more — that either don’t have an active enrollment or have enrollment information in PECOS that doesn’t match the agency’s records.”

When BKD recently looked at one client’s claims to research the issue, it found only one of eight physicians listed on a single remittance advice had a current and matching PECOS record, Little recounts. Four of the physicians had no PECOS record at all. And the agency had entered different info for three of the physicians.

For example: One doc used “Tony” as his first name in PECOS rather than “Anthony,” another used a different first name entirely, and yet another used an initial instead of a name, Little says.

Remember, it’s not a minor matter of adjusting a claim when you submit it with physician info that doesn’t match PECOS. The edits will deny your claim altogether and you’ll have to go through the costly and time-consuming appeal process for it.

Bottom line: Get your physician info correct before the edits trip up your claims May 1.

But dealing with physicians who aren’t enrolled in PECOS will be trickier than just correcting minor discrepancies. You’ll have to judge when you can still accept referrals for physicians with pending PECOS applications (see related story, p. 91).

Physicians without valid PECOS records “will be a problem for many,” warns Boyd. And few agencies will be ready for it, he predicts.

Resources: You can check CMS’s “Medi-care Ordering and Referring File” for your referring physicians at www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html. Or you can use free lookup tools such as one offered by software company HEALTHCAREfirst at www. healthcarefirst.com/free-home-care-tools/pecos- verification.aspx.

Still trying to get your docs to enroll? You may want to use a one-sheet handout with enrollment advice like this one offered by Amedisys Inc.: www.amedisys.com/assets/pdfs/5_Steps_to_PECOS_Enrollment_2012.pdf