Citing provisions contained in the Patient Protection and Affordable
Care Act passed earlier this year, the CMS has published an interim final rule
that will change the implementation date of internet-based provider enrollment
chain and ownership system (PECOS) from January 2011 to July 6. The date change comes as a
surprise to durable medical equipment orthotic and prosthetic supplies (DMEPOS)
providers who have become accustomed to the date being delayed rather than
pushed up.
Practitioners policing PECOS
O&P practitioners were admittedly shocked and left scrambling when
in October 2009, CMS began sending informational messages warning DMEPOS
suppliers that their claims would not be paid starting in January if their
referring physician was not enrolled in PECOS. Since those first messages were
sent out, the implementation date has been delayed twice — from January to
April and then again from April to Jan. 2011.
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| James P. Rogers |
In early June, the O&P community was shocked once more when they
learned that starting July 6, claims made by referring physicians not enrolled
in PECOS will not be paid and grace periods for physicians who failed to enroll
before July 6 will not be permitted.
“Part of the problem was that [CMS] delayed it first and
acknowledged that it was not fair to ask O&P providers to police
PECOS,” James P. Rogers, CPO, FAAOP, immediate past-president of the
American Academy of Orthotists and Prosthetists (the Academy) told
O&P Business News. “There is a fundamental problem with
doing that. And it is a big problem because they are penalizing the patient for
the sins of the physician and they are using us to provide their administrative
policing.”
Practitioners also acknowledge that they have little to no influence on
a physician or how they manage their practices, including whether or not they
are registered for internet-based PECOS.
“The philosophy of punishing us to try to influence the behavior of
the physicians just doesn’t make any logical sense,” Kathy Dodson,
senior director of government affairs for American Orthotic and Prosthetic
Association (AOPA) said. “If you want to change someone’s behavior
you go to them, you do not go to a third party. And that is the way CMS is
going about it, unfortunately.”
Unresponsive physicians
The physician’s failure to enroll could have dire consequences for
the O&P practitioner’s business model and more importantly, the
patient.
“In my own practice I have several nursing facilities that I care
for and the two medical directors are not PECOS registered,” Rogers said.
“We sent letters urging them to enroll. After July 6, those patients will
not be able to be cared for because of their unwillingness to sign up. It is
just going to have a profound impact on patient care.”
The O&P community scrambled once again to inform their referring
physicians who are not enrolled in PECOS to do so by July 6. Practitioners are
admittedly angry about carrying the extra educational and administrative burden
they feel belongs to CMS.
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| © 2010 iStockphoto.com/BrooksElliott |
According to Rogers, as of press time, his practice alone has sent out
approximately 200 letters during the last 30 days to four states. He knows that
he will not be reimbursed for the mailing expenses or the administrative time,
but he has no other choice.
His practice has recieved responses from 15 physicians confirming their
enrollment in PECOS. According to Rogers, that is only about 7% response rate.
The other 93% represents potentially unreimbursed patient care.
“Physicians aren’t going to respond to that. They have
administrative constraints that far exceed their capability, just like every
other medical care provider. This is just one more thing. It wouldn’t
surprise me if half of the physicians haven’t even seen the letters we
sent.”
James Bossenmeyer, director for the division of the provider and
supplier enrollment at CMS, has a more optimistic view.
“They may not get a response back, but if a practitioner did not
receive the letter, the physician may have just gone ahead and updated their
records,” he said.
For their part, since October 2009, CMS has gone from conducting general
outreach to direct mailings to physicians.
“We are seeing a significant increase in the number of physicians
and non-physician practitioners who are in the process of updating their
enrollment records,” Bossenmeyer said. “Our contractors are working
hard to process those applications as quickly as possible.”
Bossenmeyer recommends that after July 6, when a DMEPOS supplier submits
a claim, they do so with the name and the national provider identifier (NPI) of
the physician, whether or not they are enrolled in PECOS. If they are not
enrolled in PECOS, CMS will hold that claim and notify the physician. Once the
physician enrolls, then CMS will submit the claim as normal.
“We believe we understand the number of the issues that have been
raised to us, but it is important that we go through the public comment process
and carefully consider those comments as we finalize this policy,”
Bossenmeyer said.
Public comment
The comment period concluded on July 6 and Bossenmeyer insisted that CMS
will be reviewing the public comments as soon as possible to make any necessary
changes to the final ruling.
When asked of the likelihood that the public comments could sway CMS to
delay implementation, Bossenmeyer maintained that CMS will review all of the
submitted comments before making any decisions.
Dodson is not optimistic.
“If the reason for the latest date change is true, I don’t see
how they can make a change again,” Dodson said. — by Anthony
Calabro
There is definitely some confusion regarding a grace period as some
conflicting information has been issued. According to CMS Change Request 6421,
claims that include a referring provider’s name and NPI will continue to
be processed through Jan. 2, 2011 even if the referring provider is not
enrolled in PECOS. Those claims are to have an informational message warning
the patient care service provider that the referring physician is not in PECOS.
However, CMS officials have since indicated that claims may be rejected
as early as the July 6 implementation and that CMS reserves the right to
retroactively reprocess claims once the edits are in place. This could
ultimately result in CMS requesting refunds on previously paid claims. Therein
lies the confusion as to which policy will be implemented.
I can tell you that the O&P Alliance, which is comprised of the
American Academy of Orthotists and Prosthetists, the American Orthotic and
Prosthetic Association, the National Association for the Advancement of
Orthotics and Prosthetics and the American Board for Certification in Orthotics
and Prosthetics is actively involved in monitoring and responding to the PECOS
situation as it evolves. A letter has been drafted by the O&P Alliance to
the CMS, expressing concerns about PECOS and its implementation. The Alliance
will continue to stay abreast of this and other issues that affect our
profession and our patients as it has done in the past.
— Bruce “Mac” McClellan, CPO, LPO,
FISPO
Vice president, American Academy of Orthotists and
Prosthetists
