PECOS Warnings Are DME Suppliers' Latest Worry

At the latest CMS Open Door Forum on Oct. 21, the main topic on callers' minds wasn't the competitive bidding program that had just started taking bids, but the PECOS warnings newly appearing on large numbers of DME claims.

Starting this month, the Centers for Medicare & Medicaid Services (CMS) is notifying suppliers whenever a DME claim includes the name of an ordering physician or non-physician practitioner (e.g., nurse practitioner, clinical social worker, physician assistant, etc.) who is not currently in Medicare's Provider Enrollment, Chain & Ownership System (PECOS).

Right now, those notifications, which appear on the claims, are being called "informational messages." During the Open Door Forum, CMS' Jim Bossenmeyer said the affected claims are still being paid; the informational messages are intended solely to notify suppliers that the ordering physician or non-physician practitioner is not enrolled in PECOS.

But come January, claims will be denied if the ordering physician or non-physician practitioner is still not in PECOS.

The PECOS problem is coming to a head now because CMS only began issuing those informational messages in October.

Bossenmeyer added that an informational message may also be generated if the ordering physician's name isn't correct or if the NPI used on the claim was not the NPI belonging to the individual physician.

"CR 6421 requires that a claim coming in from a DMEPOS supplier include the legal business name -- that would be for example Robert Smith vs. Bob Smith -- and the individual Entity Type 1 NPI for that physician in the secondary identifier field," Bossenmeyer said during the Open Door Forum. "Currently, DMEPOS suppliers can either use their NPI number if they're not sure of the NPI number being used for ordering...as of Oct. 4, DMEPOS suppliers began receiving informational messages regarding a physician or non-physician practitioner who did not have an enrollment record with the Medicare program that has been updated since November of 2003.

"In recognizing that many DMEPOS suppliers are receiving these informational messages, we would ask that the DMEPOS supplier first begin working with their clearinghouse or their billing agent to, one, be sure that the claim is coming in with the legal business name and the NPI of the individual practitioner - that will resolve some issues for the processing. For those physicians that you continue to receive informational messages on, the DMEPOS supplier can verify if they choose (to determine whether or not the physician is in PECOS)."

While Bossenmeyer mentioned that suppliers can check PECOS to see if the physicians they work with are in the system, during the Forum's question and answer period, callers questioned the system's ease of use and how accurately that system reports whether physicians are listed or not.

(Click HERE to see the PECOS system.)

In answer to multiple questions from callers, Bossenmeyer strongly, repeatedly and categorically denied that CMS was currently considering postponing the date when warnings will become denials.

Bruce Rodman of the National Home Infusion Association was the first caller in the Q&A session, and he said that association members are reporting that large numbers of claims contain the non-PECOS warnings. Rodman said those members are concerned about those warnings turning into rejections in January.

Rose Schafhauser, executive director for the Midwest Association of Medical Equipment Services (MAMES), said in a follow-up call with Mobility Management that the MAMES members she's heard from are reporting 50 to 80 percent of their claims are carrying those warnings.

Schafhauser added that the PECOS registration process can take quite some time, easily 60 days or more - which means that even if thousands of physicians began registering in PECOS immediately, they might not meet that January deadline.

Which is why, Schafhauser says, suppliers are concerned about the PECOS issue "more than you can imagine."

The PECOS system is a database of physicians and non-physician practitioners enrolled with Medicare; the system is being used in this instance to determine whether or not physicians who order DME are Medicare-qualified to do so.

Physicians and practitioners who enrolled to work with Medicare prior to November 2003 and who have not made changes to their enrollment since then are probably not in the PECOS system. Those physicians are being asked to register with PECOS, though several Forum callers insisted that many physicians are not aware they need to do so, don't understand why they need to do so, and/or don't feel a sense of urgency to enroll.

During the Forum, Bossenmeyer confirmed that Medicare will continue to pay physicians' own claims regardless of whether or not the physicians are registered in PECOS by January.

About the Author

Laurie Watanabe is the editor of Mobility Management. She can be reached at lwatanabe@1105media.com.

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