Take PECOS seriously, stakeholders say

WASHINGTON - CMS has set a new start date for denying DME claims with the names of physicians who are not enrolled in PECOS and, this time, it may stick, industry stakeholders say.

Starting on Jan. 6, 2014, claims with the names of physicians who are not enrolled in PECOS will be denied, and the provider who submitted the claims will not be paid for the items or services that were furnished. Most recently, CMS had planned to start denying claims on May 1, 2013.

“It feels real this time,” said Kim Brummett, senior director of regulatory affairs for AAHomecare. “This has been a long, long time coming.”

This phase of the implementation of PECOS goes back to 2009. That's when CMS started sending providers this informational message when they billed with physicians not enrolled in PECOS: “Although this was paid, you have billed with a referring/ordering provider that does not match our system record. Unless corrected, this will not be paid in the future.” The messages came in as N544.

Although there have been software glitches along the way that have prevented CMS from enforcing the edits, the biggest reason for the delays: Physicians just weren't enrolling in PECOS, stakeholders say.

“They finally forced the physicians who weren't enrolled by making them not eligible for increases in payments associated with electronic medical record adoption and by suspending their billing privileges,” Andrea Stark said. “That was the final push.”

That, combined with proactive providers scrubbing their databases to make sure their information matches CMS's information, has significantly reduced the number of informational messages sent out, stakeholders say.

“We've seen a major reduction,” Stark said.

Despite the advancements, there are still several gray areas with PECOS that stakeholders are trying to get addressed. For example: Can a provider use an advanced beneficiary notice (ABN) if a physician chooses not to enroll, retires or passes away?

“What happens if a provider takes an order from a physician, delivers equipment and doesn't realize the physician is not enrolled?” Brummett said. “Can the provider hold the claim until the physician is enrolled? These things are still up in the air.”

Stakeholders say providers should take Jan. 6 very, very seriously.

“We've worried about it so many times, but it keeps getting delayed, so it's hard for anyone to take it seriously,” said Kelly Wolfe, CEO of Regency Billing and Consulting. “That needs to change.”