Home Health & Hospice Week

You can't use ABNs for docs lacking PECOS records, final rule says.

The PECOS-related claims denial catastrophe that CMS avoided last year is back on deck.

Background: In May 2010, the Centers for Medicare & Medicaid Services published an interim final rule based on the Affordable Care Act, requiring physicians who ordered home health and certain other services to be enrolled in PECOS with a valid National Provider Identifier (NPI) number for claims to be paid. CMS planned to begin editing for docs' NPIs and PECOS information in January 2011. However, CMS postponed those edits indefinitely when physicians had inordinate difficulty enrolling in the system, among other problems.

In a new final rule scheduled for publication in the April 27 Federal Register, CMS confirms its plans to move ahead with its NPI and PECOS requirements for physicians ordering home health services. And it confirms its plans to implement the dreaded PECOS edits too -- sometime. "We will provide advance notice to providers and suppliers of the date we plan to activate the automated edits that would cause a claim not to be paid for the lack of an enrollment record in Medicare," CMS says in the rule.

That timeline may be sooner than the rule indicates, says the National Association for Home Care & Hospice. "A CMS official, in a conversation with ... NAHC, stated that this final rule serves as a notice of plans to activate home health claim edits for Medicare enrolled physicians, possibly as early as the effective date, which is 60 days after date of the publication in the Federal Register," NAHC warns.

Do this: "Home health agencies should im-mediately begin checking every physician's Medi-care enrollment status in the Ordering and Referring Physician report," the trade group urges. "The reports will be updated weekly." The report is at www.cms.gov/Medicare/Provider-Enrollment-and-Certification/MedicareProviderSupEnroll/MedicareOrderingandReferring.html under the "Downloads" section.

HHAs have plenty of ways to check for a provider's PECOS status, CMS maintains in the rule. "Information regarding a provider or supplier's enrollment status is available by checking the files we post on the Medicare provider/supplier enrollment website, or by inquiring with the ordering or certifying providers," the agency says.

Remember: "A home health agency can and should ask the ordering/certifying physicians if they are enrolled in Medicare or have opted out of Medicare prior to accepting the order and/or certification," the rule directs.

Will CMS Use Retroactive PECOS Recoupments?

The rule has good news about which claims will be affected by the PECOS edits. "The edits will apply to only those claims with a date of service on or after the date the edits are activated," the rule says.

But CMS doesn't close the door on making recoupments retroactive to the July 2010 effective date of the requirement. At the time, CMS wouldn't commit to such a ban (see Eli's HCW, Vol. XIX, No. 26, p. 202).

All CMS promises in the rule is that "no part of this final rule will require retroactive compliance for periods of time before July 6, 2010." And it says that "we always retain the right to pursue fraud and recoup money for claims that did not meet the requirements of the IFC. However, for operational reasons, we do not believe it would be a prudent use of resources to pursue large-scale recoveries against claims with dates of service from July 2010 until such time as we activate prepayment edits that identify claims that do not have proper documentation of enrolled ordering and/or certifying suppliers."

It has taken long enough for CMS to implement this rule, which has a fraud-fighting mission, Senate Finance Committee Ranking Member Orrin Hatch said in a statement at the committee's April 24 hearing on fraud investigations (see related story, p. 122).

Many of the comments in the rule pertained to the originally proposed deadline for the PECOS requirement being unworkable. CMS's postponement of the PECOS edits has made those points moot.

But CMS may not be as lenient once the edits take effect. "We do not believe it is necessary to hold home health agencies harmless if the ordering/certifying provider reported in their claims is not enrolled in Medicare in an approved status or has not validly opted out of Medicare," the agency says in the final rule.

Don't think you can ease your cash flow by securing payment on your requests for anticipated payment (RAPs) if docs are slow to enroll in PECOS. When the PECOS edit is turned on, it "will apply to both the RAP and the final claim," CMS clarifies in the rule.

And you won't be able to secure payment from the beneficiary if the physician won't enroll. "The denial of a claim for lack of an approved enrollment record in Medicare is not a coverage determination; hence the HHABN is not applicable," CMS says of the possibility of using an advance beneficiary notice.

Note: The rule is at https://s3.amazonaws.com/public-inspection.federalregister.gov/2012-09994.pdf.