Medicare Compliance & Reimbursement

Ensure that patients don’t suffer because of noncompliant physicians.

Hopefully the vast majority of your ordering physicians will have PECOS enrollment under their belts, leaving the new PECOS edit implementation date to have little effect on you. But don’t count on it.

Nearly every home health agency will have some referring physicians who haven’t complied with Medicare’s order to enroll in PECOS — and for many agencies, the level of denials will be shocking, billing expert Melinda Gaboury with Healthcare Provider Solutions in Nashville, Tenn., recently told Eli.

If you’re lucky, your denials will mostly occur because the information you put on your claim does not exactly match the doc’s record in PECOS. The edits will check whether the physician’s NPI is in Medicare’s Ordering/Referring File, whether the name for the NPI exactly matches the one in the file, and whether the doc is of a specialty that’s allowed to order/refer home health services, Home Health & Hospice Medicare Administrative Contractor CGS explains in its January bulletin for providers. “The edits will compare the first four letters of the last name,” CGS reminds agencies.

Tip: Do not put credentials, nicknames or suffixes like “Jr.” in the ordering/referring fields on the claim, CGS instructs.

When the edits kick out your claim because of a name or number mismatch, you’ll need to file an appeal — not an adjustment, CGS stresses. But at least you’ll eventually obtain your rightful reimbursement.

Prepare To Help Potential Patients Find New Physicians

When the ordering physician isn’t enrolled in PECOS at all, then you just flat won’t get paid. And you can’t seek payment from the patient, either. CMS repeatedly has told providers they may not bill patients via an Advance Beneficiary Notice when the doc lacks PECOS enrollment, notes the National Association for Home Care & Hospice.

When you run into patients whose physicians aren’t PECOS enrolled, you need to be ready. NAHC advises taking these steps to establish a PECOS edit “crisis management plan”:

1. Compile a list of alternative physicians who are Medicare enrolled.
2. Compose a prepared statement to give to affected patients. The statement should explain in layman’s terms the PECOS edits and their effect on the patient’s admission.
3. Generate a statement for docs. When a physician’s patient is denied admission due to her lack of PECOS enrollment, you should send her a prepared statement explaining the reason. Include directions for how to enroll in PECOS for future referrals, NAHC suggests.

“Home health agencies should not be criticized for the failure of physicians to take the simple steps necessary to enroll,” NAHC says in its member newsletter. “Patients should not be relegated to confusion.”