Medicare Compliance & Reimbursement

Tip: Review what’s in PECOS as soon as possible.

If you’re already worried about denials, here’s another item to add to your claims checklist. The Centers for Medicare and Medicaid Services (CMS) is slated to reject hospital claims for Medicare services furnished at off-campus provider-based departments (PBDs) when the addresses don’t match up exactly with what’s in Provider Enrollment, Chain and Ownership System (PECOS) — starting in July.

Background: The timeline for this address implementation is significant and started with site-neutral requirements outlined in the Bipartisan Budget Act of 2015 (BBA 2015). In fact in a March 2019 release, CMS reminds providers that it should come as no surprise since it “discussed these requirements in CRs 9613 and 9907, both of which were effective on January 1, 2017,” notes MLN Matters SE 19007.

Plus: Medicare providers shouldn’t expect any favors on the “exact match” policy either. The agency points out that providers knew the edits were coming for more than two years and had “ample time” to prepare, update their procedures, and fix any PECOS issues, the MLN Matters release says.

Tip: You can find more formal guidance on the requirement in the Medicare Claims Processing Manual, Chapter 1, Section 170 at www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c01.pdf.

Confirm Your PECOS Details ASAP

There are so many ways this could go wrong for providers — lack of procedures, confused staff, misunderstanding over CMS policy, incorrect entry, and more. However, checking PECOS should probably be at the top of your to-do list before you submit any new Medicare claims.

“The primary action item that a hospital should undertake now is to review the enrollment address for each of its PBDs in the PECOS system,” advises attorney Valerie Breslin Montague, a partner with Nixon Peabody LLP in Chicago.

She adds, “A hospital should ensure that the address in PECOS exactly matches the address on a claim for PBD services, paying particular attention to any use of abbreviations, such as ‘Ste.,’ ‘Rd.’ or ‘Ave.’”

Practices and hospitals may be aware of the policy requirement, but business associates may not. That’s why it’s essential to double-check with your outside resources to ensure they have your address as it appears in PECOS, too.

“Although an organization’s workforce (and vendors) can be one of its greatest strengths, it can also be the weakest link,” Montague explains. “Hospitals should ensure that any personnel involved in the PBD claims submission process, as well as any vendors, if the hospital outsources this function, are aware of the CMS ‘exact match’ policy.”

Consider these four tips to combat adverse address issues and turnaround denials:

1. Verify address. Hospitals must confirm their addresses in PECOS and make sure all parties have the exact match. “CMS recently enabled a new query function so that a hospital can confirm its address in PECOS and ensure that address matches the address of the location where the service was provided, as indicated on Medicare outpatient claims,” counsel attorneys Cecilie H. MacIntyre and Gary A. Rosenberg with national firm Verrill Dana LLP in online analysis.

2. Identify the denial reason. If there’s an address issue, Medicare providers need to find the source. “If a hospital is faced with denied claims due to PBD addresses that do not match what is listed in PECOS, it should first identify the cause for the non-matching address on the denied claims,” Montague says.

3. Fix the address problem. After you’ve let everyone know about the address snafu, correct the mistake and ensure everyone has the right match. “The hospital should resolve that issue, whether by providing a billing company the accurate address, retraining staff on this issue, or otherwise,” she maintains.

4. Re-submit quickly. Montague recommends resubmitting Medicare claims sooner rather than later. “Simultaneously, or as soon as possible thereafter, the hospital should work as diligently as possible to resubmit the denied claims so that these claims are not denied a second time for a lack of timely filing.”

Resource: Review MLN Matters SE 19007 www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/SE19007.pdf.