Medicare Compliance & Reimbursement

Lack of clarity on how the edits will impact RAPs.

There is still some measure of confusion which the Centers for Medicare & Medicaid Services (CMS) needs to clarify with regard to how the PECOS edits will impact Requests for Anticipated Payment (RAPs) for episodes starting Jan. 6 or later. The edits affect claims with a “From” date of Jan. 6 or later. That means your end of episode claims for episodes that began before Jan. 6 will not be affected by the newly enforced requirement.

Home Health & Hospice Medicare Administrative Contractor CGS says that “if the attending physician name submitted on the [RAP] does not exactly match the name in the PECOS file, no RAP payment will be made.” But the National Association for Home Care & Hospice (NAHC) says that CMS has indicated “RAPs are not subject to the edits and will continue to process as they do now.”

The CGS statement “is in direct conflict with what CMS stated to me in an email,” NAHC’s Mary Carr tells Eli. Confusion may have stemmed from an initial, erroneous CMS explanation that RAPs would pay at zero if the RAP didn’t pass the edit, Carr suggests.

Remember: To pass PECOS edits, be sure to use the physician’s individual NPI, not her group or organization number, CGS reminds providers.

While physician enrollment in PECOS has improved markedly since the Affordable Care Act mandated the edits, home health agencies should still prepare to see denials for docs who haven’t jumped on the PECOS bandwagon. “The VA physicians are particularly deficient — apparently because they still, mistakenly, believe that they do not need to enroll as they are not paid by Medicare for physician services,” NAHC observes.

Warning: Remember that you can’t merely adjust claims that fail the edit. Instead, you have to file an appeal. The good news is that CMS will consider a physician’s PECOS enrollment effective from the date he submits an enrollment application to his carrier, NAHC says.

Advice: Check a physician’s PECOS status upon referral and before each subsequent episode, NAHC counsels.

Bitter pill: If the doc is not enrolled in PECOS, you’ll need to turn down his referral, NAHC advises.

Another option: You also may help the patient find a new physician who is enrolled in PECOS, NAHC suggests.