Reprinted with permission from AOPA In Advance, a publication of the American Orthotic & Prosthetic Association (AOPA)
The Centers for Medicare and Medicaid Services (CMS) has published a change to the date by which referring physicians must have active accounts in the Provider Enrollment Chain and Ownership System (PECOS), from January 3, 2011 back to July 6, 2010. According to Jim Bossenmeyer from CMS, the earlier implementation date is a requirement of provisions contained in the Patient Protection and Affordable Care Act (PPACA) passed earlier this year. In order for a physician's or other qualified healthcare practitioner's referral or order to be considered valid for Medicare claim submission purposes, it must come from a provider with a current PECOS enrollment record. Originally scheduled for implementation on January 4, 2010, the PECOS requirement has been delayed several times in order for CMS to develop proper system edits to properly enforce it. While Mr. Bossenmeyer stated in a May 26, 2010 CMS Open Door Forum that PECOS system edits may not be fully functional by July 6, CMS reserves the right to reprocess claims that should not have been paid due to an invalid referral once the edits are fully functional. This means that you may still get paid for claims with an invalid referral; however your DME MAC may come back later and request a refund. The four DME MACs are continuing to generate warning notices when services are referred by physicians who do not have a current PECOS record. If you receive one of these notices, you need to first check that the provider information submitted on your claim included the provider's correct individual NPI number and name. The name must be in all capital letters and match what the physician entered in the NPI registry system. The referral physician's name on the claim information should not contain credentials (e.g. MD), titles, or punctuation, except for the hyphen in hyphenated names, and must not be a nickname (e.g. use Robert, not Bob). If all the information you entered on the claim was correct, go back to your referral sources to let them know that in order to continue to refer Medicare beneficiaries for services, they must be enrolled in PECOS by July 6, 2010. AOPA has prepared a sample letter that may be used to educate referral sources of this important requirement.
Click here to download the sample letter.
In addition, you should be checking on a physician's PECOS status when you receive a prescription from a new referral source, to make sure that he/she is in PECOS before treating the patient. If the physician is not in PECOS, your claim will either be denied or will be subject to later recoupment. CMS has published a directory of PECOS enrolled physicians that may be used to verify that your referral sources are indeed eligible to prescribe services for Medicare patients. This directory may be found by clicking here, although it is difficult to use since it is not easily searchable. However, Paul Prusakowski of oandp.com has created a PECOS search engine that will greatly aid in searching the PECOS directory released by CMS. He has made it available and given free access to all of O&P for its use. Click here to access the searchable version of the PECOS database.