Home Health & Hospice Week

You won't have any financial recourse if Medicare denies an episode that's supposed to pay thousands due to referring physician eligibility. So you'd better make sure your claims are free of such problems.

"When it turns out that the physician has been excluded from Medicare or is not properly enrolled (or opted out), the penalty falls on the home health agency because accepting orders from an appropriately credentialed physician is an administrative requirement," notes Chicago-based regulatory consultant Rebecca Friedman Zuber.

Heed this expert advice to head off claims denials related to physician eligibility:

1. Check for the doc's NPI and PECOS record. The deadline for PECOS edits has been indefinitely postponed, points out consultant Judy Adams with Adams Home Care Consulting in Chapel Hill, N.C. That means you won't receive a returned claim at the outset when a physician isn't enrolled -- you could provide episode after episode under an ineligible physician's orders.

HHAs need to be sure the MD has a National Provider Identifier (NPI) number and has applied for enrollment in the online Provider Enrollment, Chain, and Ownership System (PECOS), Adams advises. The Centers for Medicare & Medicaid Services has been pushing PECOS enrollment to physicians, which may help boost referring docs' PECOS enrollment rates (see Eli's HCW, Vol. XX, No. 34, p. 267).

Resources: You can check the NPI registry at https://nppes.cms.hhs.gov/NPPES/NPIRegistryHome.do. You can check for your physician's record in PECOS at www.cms.gov/MedicareProviderSupEnroll/06_MedicareOrderingandReferring.asp -- scroll down to the "Downloads" section. Or you can search for PECOS records with free websites such as www.oandp.com/pecos.

The problem for many agencies is that searching these databases takes personnel and time, Zuber points out.

2. Know when to check. HHAs should check "every physician when they take the first patient under that physician," Adams recommends. And agencies should check periodically thereafter to be sure the MD is still enrolled with Medicare.

You may let a longer time elapse between database searches for physicians you are very familiar with, and set shorter check intervals for "physicians with whom [you] do not have a lot of experience," Zuber suggests.

And it's smart to make a check whenever you see any red flags about a physician. "Be vigilant and question sudden changes in practice patterns," Zuber urges.

3. Decide what to do next. What happens if you check PECOS and your referring physician isn't in it? "Take steps to determine whether the physician is enrolled in Medicare and advise him/her to enroll in PECOS," counsels the National Association for Home Care & Hospice in its member newsletter.

Problem: Physicians may assure agencies that their PECOS application is just pending, points out consultant Tom Boyd with Rohnert Park, Calif.- based Boyd & Nicholas. In this case, agencies should get a written signature from the doctor saying he is signed up, Boyd advises.

And agencies might even consider not taking any patients from those physicians who say their applications are pending. "This would be hard," though, Boyd admits.

4. Check the OIG exclusion list. It's not just Medicare enrollment you have to worry about. Medicare will also deny entire claims when the physician is excluded from the Medicare program. And the HHS Office of Inspector General can levy fines against the provider.

"Check every physician against the Medicare exclusion list," Adams urges. Links to the list are at http://oig.hhs.gov/exclusions/index.asp.

5. Educate physicians. Just because referring physicians don't bill Medicare doesn't mean they get a pass on Medicare enrollment. HHAs should educate Veterans Administration and other physicians that do not bill Medicare to complete an 855O, NAHC counsels. The 855O "is an abbreviated enrollment form developed specifically for them," the trade group explains.