PECOS confusion: responses
Stephan Manucharian
Description
Collection
Title:
PECOS confusion: responses
Creator:
Stephan Manucharian
Date:
8/27/2010
Text:
Dear List,
After having received many responses from the members I realized that I was
not alone in not fully understanding how to interpret the PECOS regulations.
As I wrote in the enquiry, we failed to find written reference on Medicare
site about July 6 date and called them to learn that the date is actually
January of 2011.
I received many responses from companies that also, contacted Medicare to
clarify the dates and were told that it is in fact January of 2011, so
continued their business as usual for the time being.
However, I did receive a copy of communication that came directly from the
government source, which I am attaching below. Additionally, I received a
response from Kathy Dodson of AOPA, with further clarification (read:
interpretation) of the law.
After absorbing the information attached below, the only question that is
still not clear is whether there is a chance that Medicare will *retroactively
*review claims.
CMS TO REVIEW PECOS ENROLLMENT PROCESS (201006-57)
Medicare Working with Ordering and Referring Providers and Suppliers to
Streamline Enrollment Process
The Centers for Medicare & Medicaid Services (CMS) is working with providers
to address concerns about enrollment in the Provider Enrollment, Chain and
Ownership System (PECOS) to ensure that Medicare beneficiaries continue to
receive the health care services and items they need. PECOS is the
electronic system used to enroll physicians and eligible professionals into
the Medicare program.
As part of those efforts, CMS will, for the time being, not implement
changes that would automatically reject claims based on orders,
certifications, and referrals made by providers that have not yet had their
applications approved by July 6, 2010. While more than 800,000 physicians
and other health professionals have enrolled and have approved applications
in the PECOS system, some providers have encountered problems. CMS is
continuing to update and streamline the process, and more providers have
been enrolled in the past few days.
CMS issued an interim final regulation on May 5, 2010 implementing
provisions of the Affordable Care Act that permit only a Medicare enrolled
physician or eligible professional to certify or order home health
services, durable medical equipment, prosthetics, orthotics, and supplies
(DMEPOS) , and certain items and services under Medicare Part B. The new
law applies to orders, referrals and certifications made on or after July
1. The comment period for the regulation closes on July 6, after which the
comments will be reviewed and considered before a final regulation is
issued.
The Affordable Care Act provisions and the regulation were designed as steps
to prevent fraud in Medicare by ensuring that only eligible and identifiable
providers and suppliers can order and refer covered items and services to
Medicare beneficiaries.
Many physicians and other providers and suppliers have continued to make
good faith efforts to comply with the requirements of the law and
regulation. These efforts will be a significant factor in determining the
procedures and processes that will be incorporated in the final rule.
While the regulation will be effective July 6, 2010, CMS will not implement
automatic rejections of claims submitted by providers that have attempted to
enroll in PECOS. However, until the automatic rejections are operational,
providers should not see any change in the processing of submitted claims,
they will continue to be reviewed and paid as they have historically been
reviewed and paid.
Additionally, though CMS is taking a more deliberative approach to using the
PECOS enrollment system, the agency will employ a contingency plan to meet
the ACA requirement that written orders and certifications are only issued
by eligible professionals effective July 1.
CMS will continue to send informational notices to providers reminding them
of the need to submit or update their enrollment and will work with the
provider community to provide guidance on enrollment and will process all
applications expeditiously.
FROM AOPA: Hopefully I can help clear up this confusion. The problem lies
in the difference between the date that a law goes into effect and when CMS
decides to act on it, as well a lack of decision-making by CMS.
The law that says that CMS must only pay for services based upon referrals
from eligible physicians went into effect on July 6, 2010. I've attached
the Federal Register notice announcing this (see the heading Dates on the
first page.) However, CMS, the federal agency that administers the Medicare
program, has chosen not to implement the denial of ineligible claims until
January of next year. This was an internal administrative decision made by
CMS on how to implement the law.
Confusion also stemmed from the fact that CMS (the central office located in
Baltimore, MD, responsible for overseeing the Medicare program) did not tell
the DME MACs (the insurance companies that pay your claims and that most
people think of as “Medicare”) about the July 6 effective date. In
addition, CMS for many weeks flip-flopped on the date that it would actually
being denying claims. Sometimes it was July and sometimes it was January.
So the DME MACs were left hanging with no “official” information. This
meant that when O&P facilities “called Medicare (their DME MACs)”, they were
told that the rule was not going into effect until next year, even though
CMS had not yet made this decision.
Finally, CMS got their act together and announced that claims denials would
not start until January of 2011. So currently, claims submitted based upon
an “ineligible” referral are still being paid, and will be until January.
I hope this helps explain the confusion concerning PECOS implementation.
Kathy
Kathy Dodson
Senior Director of Government Affairs
American Orthotic and Prosthetic Association
--
*Stephan R. Manucharian, M.A., MSc, CP, BOCO
Clinical Director
Orthopedic Arts Laboratory, Inc.
141 Atlantic Ave., Brooklyn, NY 11201
718-858-2400; Fax: 718-858-9258;
<URL Redacted> < <URL Redacted>>
Non est vivere sed valere vita est!
The content of this communication is for exclusive use of the addressee and
may contain confidential, privileged and non-disclosable information. If the
recipient of this communication is not the addressee, such recipient is
strictly prohibited from printing, photocopying, saving on any media,
distributing or otherwise using the information contained herein. If you
received this communication in error, please contact the sender by e-mail,
fax or telephone and destroy this document.
*
After having received many responses from the members I realized that I was
not alone in not fully understanding how to interpret the PECOS regulations.
As I wrote in the enquiry, we failed to find written reference on Medicare
site about July 6 date and called them to learn that the date is actually
January of 2011.
I received many responses from companies that also, contacted Medicare to
clarify the dates and were told that it is in fact January of 2011, so
continued their business as usual for the time being.
However, I did receive a copy of communication that came directly from the
government source, which I am attaching below. Additionally, I received a
response from Kathy Dodson of AOPA, with further clarification (read:
interpretation) of the law.
After absorbing the information attached below, the only question that is
still not clear is whether there is a chance that Medicare will *retroactively
*review claims.
CMS TO REVIEW PECOS ENROLLMENT PROCESS (201006-57)
Medicare Working with Ordering and Referring Providers and Suppliers to
Streamline Enrollment Process
The Centers for Medicare & Medicaid Services (CMS) is working with providers
to address concerns about enrollment in the Provider Enrollment, Chain and
Ownership System (PECOS) to ensure that Medicare beneficiaries continue to
receive the health care services and items they need. PECOS is the
electronic system used to enroll physicians and eligible professionals into
the Medicare program.
As part of those efforts, CMS will, for the time being, not implement
changes that would automatically reject claims based on orders,
certifications, and referrals made by providers that have not yet had their
applications approved by July 6, 2010. While more than 800,000 physicians
and other health professionals have enrolled and have approved applications
in the PECOS system, some providers have encountered problems. CMS is
continuing to update and streamline the process, and more providers have
been enrolled in the past few days.
CMS issued an interim final regulation on May 5, 2010 implementing
provisions of the Affordable Care Act that permit only a Medicare enrolled
physician or eligible professional to certify or order home health
services, durable medical equipment, prosthetics, orthotics, and supplies
(DMEPOS) , and certain items and services under Medicare Part B. The new
law applies to orders, referrals and certifications made on or after July
1. The comment period for the regulation closes on July 6, after which the
comments will be reviewed and considered before a final regulation is
issued.
The Affordable Care Act provisions and the regulation were designed as steps
to prevent fraud in Medicare by ensuring that only eligible and identifiable
providers and suppliers can order and refer covered items and services to
Medicare beneficiaries.
Many physicians and other providers and suppliers have continued to make
good faith efforts to comply with the requirements of the law and
regulation. These efforts will be a significant factor in determining the
procedures and processes that will be incorporated in the final rule.
While the regulation will be effective July 6, 2010, CMS will not implement
automatic rejections of claims submitted by providers that have attempted to
enroll in PECOS. However, until the automatic rejections are operational,
providers should not see any change in the processing of submitted claims,
they will continue to be reviewed and paid as they have historically been
reviewed and paid.
Additionally, though CMS is taking a more deliberative approach to using the
PECOS enrollment system, the agency will employ a contingency plan to meet
the ACA requirement that written orders and certifications are only issued
by eligible professionals effective July 1.
CMS will continue to send informational notices to providers reminding them
of the need to submit or update their enrollment and will work with the
provider community to provide guidance on enrollment and will process all
applications expeditiously.
FROM AOPA: Hopefully I can help clear up this confusion. The problem lies
in the difference between the date that a law goes into effect and when CMS
decides to act on it, as well a lack of decision-making by CMS.
The law that says that CMS must only pay for services based upon referrals
from eligible physicians went into effect on July 6, 2010. I've attached
the Federal Register notice announcing this (see the heading Dates on the
first page.) However, CMS, the federal agency that administers the Medicare
program, has chosen not to implement the denial of ineligible claims until
January of next year. This was an internal administrative decision made by
CMS on how to implement the law.
Confusion also stemmed from the fact that CMS (the central office located in
Baltimore, MD, responsible for overseeing the Medicare program) did not tell
the DME MACs (the insurance companies that pay your claims and that most
people think of as “Medicare”) about the July 6 effective date. In
addition, CMS for many weeks flip-flopped on the date that it would actually
being denying claims. Sometimes it was July and sometimes it was January.
So the DME MACs were left hanging with no “official” information. This
meant that when O&P facilities “called Medicare (their DME MACs)”, they were
told that the rule was not going into effect until next year, even though
CMS had not yet made this decision.
Finally, CMS got their act together and announced that claims denials would
not start until January of 2011. So currently, claims submitted based upon
an “ineligible” referral are still being paid, and will be until January.
I hope this helps explain the confusion concerning PECOS implementation.
Kathy
Kathy Dodson
Senior Director of Government Affairs
American Orthotic and Prosthetic Association
--
*Stephan R. Manucharian, M.A., MSc, CP, BOCO
Clinical Director
Orthopedic Arts Laboratory, Inc.
141 Atlantic Ave., Brooklyn, NY 11201
718-858-2400; Fax: 718-858-9258;
<URL Redacted> < <URL Redacted>>
Non est vivere sed valere vita est!
The content of this communication is for exclusive use of the addressee and
may contain confidential, privileged and non-disclosable information. If the
recipient of this communication is not the addressee, such recipient is
strictly prohibited from printing, photocopying, saving on any media,
distributing or otherwise using the information contained herein. If you
received this communication in error, please contact the sender by e-mail,
fax or telephone and destroy this document.
*
Citation
Stephan Manucharian, “PECOS confusion: responses,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 7, 2024, https://library.drfop.org/items/show/231721.
