Consider it a game of “now you see it, now you don’t, now you see it again.” After it briefly announced last week that Phase 2 of the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) will go into effect May 1, and then just as quickly retracted that announcement, the Centers for Medicare and Medicaid Services now has formally announced that the program will indeed go into effect on May 1.
As of that implementation date, any Medicare claims for home medical equipment (HME), Part B, and Part A home health agency that are prescribed by healthcare professionals who are not enrolled in CMS’s PECOS system will be denied.
The first phase began Oct. 5, 2009 with CMS telling providers that any Medicare claims had to come from prescriptions issued by physicians and healthcare professionals in the PECOS system. Due to the difficulty physicians had enrolling in the system, the low initial number of physicians enrolled, and initial difficulties providers were having checking to see if their referral partners were indeed enrolled, Phase 2 was delayed until now.
Come May 1, CMS makes the claims denials effective, so that physicians and other referring health professionals must be enrolled in the system and their record must specify they are eligible to order and refer Part B, DME, and Part A HHA claims. Otherwise Medicare will not approve those claims.
The full details of the CMS’s announcement can be read in MLN Matters SE1305. The MLN Matters offers various instructions on what providers making claims coming from referral sources need to do to ensure their claims go through. A key reminder is that they should use full names of physicians, and to use the referral’s individual NPI and not that of his or her organization.
CMS estimates that fewer than 1 percent of ordering physicians have not enrolled in PECOS. According to HMEB’s current online survey, 60 percent of providers say 75 percent or more of their referring physicians are enrolled.
