PECOS: What a long and strange trip it's been

When we reported in late May that, per an interim final rule published that month, physicians must enroll in the Provider Enrollment, Chair and Ownership System (PECOS) by July 6, not Jan. 3, we were inundated with e-mails and phone calls.

This can't be, providers said!

Because we based our initial story on an Open Door Forum, providers, justifiably, wanted to read the news somewhere other than HME News. Here's the interim final rule published in the Federal Register, and note this paragraph (bold added for emphasis):

We are requiring at a new Sec.  424.507(c) that Medicare contractors will reject claims from providers and suppliers for the  above-described covered ordered or referred items or services if the legal names and the NPIs are not reported in the claims or, with the  exception noted below, if the ordering or referring supplier does not  have an approved enrollment record in PECOS.

And note the deadline:

These regulations are effective on July 6, 2010.

But confusion remained. So for good measure we called CMS's Jim Bossenmeyer and asked him a handful of questions, including: Does CMS expect DME providers to submit PECOS compliant claims starting July 6 (yes, he said); and what if providers submit non-compliant claims on or after July 6 (they will be in violation of the rule, he said).

There was still confusion, fueled by reports that, while the rule would go into effect July 6, CMS won't have edits in place by then. That's true (Bossenmeyer acknowledged to HME News that the edits have not been finalized), but what does that mean? Does it mean that providers and physicians have an undetermined amount of time after July 6 to get their act together?

Not exactly. As we reported in our initial story, CMS reserves the right to go back and reprocess claims to make sure providers and physicians are compliant starting July 6.

This week, the healthcare attorneys at Brown & Fortunato, via a NAIMES bulletin, offered their interpretation of the interim final rule and it jibes with what HME News has been reporting all along (We hate to say we told you so, but...):

We performed some research and ran a few traps. With the information we have thus far, we have concluded that effective 7/6, a claim will not be eligible to be reimbursed if it results from an order from a physician who is not PECOS-registered.

We do not think that the carriers will have the edits in place to reject claims beginning 7/6, meaning that claims (resulting from orders from non-PECOS registered physicians) will likely be paid.

However, if the DME supplier is later subjected to a post-payment audit, then claims previously paid (resulting from orders from non-PECOS registered physicians) will be subject to recoupment.  If a supplier submits claims that it knows result from orders from non-PECOS registered physicians, then the supplier could be liable under the False Claims Act.

Likewise, if a supplier later discovers that claims it previously submitted resulted from orders from non-PECOS registered physicians, and if the supplier does not voluntarily repay the claims, then the supplier could be liable under the False Claims Act.

When you're dealing with CMS, however, certainties are hard to come by. One provider e-mailed us recently to point out that the DME MACs are still publishing bulletins with the Jan. 3 deadline. All we can say is: It must take a while for CMS and its contractors to get on the same page?

If there's anything HME News underreported about PECOS, it's this: CMS is collecting comments on its interim final rule until July 6, and when we asked Bossenmeyer when the edits would be finalized and whether CMS would edit claims retroactively, he said the answers to these questions would be "based on comments we receive." Though "an interim final rule is a final rule being enforced," he said, "it may be tweaked based on public input."

Maybe—and it's a big maybe—there's at least an opportunity to get the edits formally delayed to, say, Jan. 3, if providers scream hard enough?

So before you pack your bags for that long 4th of July weekend, I suggest you drop an e-mail to CMS. You can submit electronic comments to http://www.regulations.gov. Use the file code CMS-6010-IFC.

I'll leave you with this: I had a conversation with a provider in a competitive bidding area earlier this week, and naturally, he's worried about the bid amounts that CMS plans to unveil today. He asked me, "Have you heard anything about the announcement being delayed?" and "Have you heard if H.R. 3790 will get passed?" I had to tell him no on both accounts.

Then the provider asked, half-joking, "Well, can you just write something to that effect? If you write it, I'll believe it."

We never like to be the bearer of bad news—like the PECOS deadline coming six months earlier than expected—but you can rely on HME News to report the truth and not sugar coat it.

Liz Beaulieu