News from the AOA's Blog

Medicare is, at least for the moment, continuing to process claims for products and services as usual – even when they have been ordered by health care practitioners who do not have a complete Medicare enrollment record in the database known as the Provider Enrollment, Chain and Ownership System (PECOS) – while U.S. Centers for Medicare & Medicaid Services (CMS) officials finalize a new regulation requiring Medicare enrollment data to be included in PECOS, work to simplify the Medicare enrollment procedure, and attempt to clear a backlog of enrollment applications from health care practitioners now in the system.

However, that will change in the coming months as the final regulation on Medicare ordering and referring is released, CMS officials emphasize.

Health care practitioners who wish to ensure Medicare will honor claims for any durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) they order, or any services to which they refer patients, should have a complete or pending Medicare enrollment application in the PECOS database.

The AOA Advocacy Group is continuing to urge all optometrists with Medicare patients – particularly those who enrolled as Medicare physicians prior to November 2003 when the CMS began using the PECOS database to house Medicare enrollment information  – to see if they are included in the Medicare enrollment records and, if necessary, re-enroll as Medicare providers. 

Physicians can re-enroll in Medicare using paper forms (CMS-855) or online (Internet-based PECOS) (see “PECOS help at a glance”).

Health care practitioners can determine if they have a complete record in the PECOS enrollment database, and are therefore eligible to order and refer under Medicare, by consulting the Medicare Ordering and Referring File on the CMS Web site. The CMS also announced last month a new online Initial Physician Applications Pending Contractor Review File through which health care practitioners can document that they have an enrollment application pending in PECOS (see related story).

Optometrists have always needed to be enrolled in Medicare to be a participating or nonparticipating physician treating Medicare beneficiaries and receiving reimbursement.

The difference now is that the doctor’s enrollment information must be added to the PECOS database. Doctors who have enrolled since 2003 are included in PECOS. Doctors who began seeing Medicare patients prior to November 2003 must submit a new Medicare enrollment application to be added to PECOS. 

A new interim Medicare rule, requiring “ordering/ referring” practitioners to have enrollment information in the PECOS database officially took effect at the beginning of July (see the July 2010 AOA News).

Under terms of the interim rule, effective July 6, Medicare could automatically reject any claims for products or services that were not based on orders or referrals from PECOS providers.  However, CMS officials indicated in a letter to practitioners they would not immediately seek to enforce the new rule.

Instead, CMS officials told health care trade media that they would initiate active enforcement only after issuing a final version of the rule. They cited a need to consider health care provider response to the rule, gathered during a public comment period that closed on the same day the interim regulation took effect.

A few days later, CMS officials announced they were reviewing the PECOS enrollment process and would work with health care providers to “streamline” the system.

As the result of a series of actions by the CMS over recent months to encourage Medicare provider enrollment, some 26,000 physician enrollment applications are now pending in the system, agency officials noted.

“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,” agency officials said. “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 (since the system was initiated in 2003) 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,” the agency added.

Medicare enrollment – on paper or online – is notoriously problematic among physician organizations. Unfriendly policies and procedures, as well as constantly changing rules, make it difficult for office staff and Medicare contractor staff to have all of the correct information. 

Medicare contractors typically take 60 days to process a paper enrollment application and 45 days to process an online application but the online process requires several time-consuming steps before the application can be formally submitted.

Among the most vocal critics have been practitioners who enrolled as Medicare providers prior to the national launch of the PECOS system in November 2003 and who now must re-enroll in Medicare through the PECOS in order to meet the new rules.

For such practitioners, re-enrolling in Medicare through the PECOS entails the disruption of Medicare payments while the reenrollment application is processed, the AOA Advocacy Group notes.

The interim regulation that took effect last month implements provisions of this year’s federal health care reform law, the Patient Protection and Affordable Care Act (PPACA) designed to fight Medicare abuse in the durable medical equipment industry.

The new regulation is pertinent to optometry because Medicare considers post-cataract eyeglasses to be DMEPOS and claims for such eyewear could be subject to rejection if the prescriber does not meet the enrollment requirement, the AOA Advocacy Group notes.

“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,” according to a CMS statement.

“CMS will not implement automatic rejections of claims submitted by providers that have attempted to enroll in PECOS,” the agency statement continues. 

In addition, claims that are eventually rejected under this policy can be re-submitted once the ordering or referring physician re-enrolls in Medicare. CMS officials add that although they are “taking a more deliberative approach to using the PECOS enrollment system, the agency will employ a contingency plan to meet the PPACA requirement that written orders and certifications are only issued by eligible professionals effective July 1.”

CMS officials say they will continue to send informational notices to providers reminding them of the need to submit or update their Medicare enrollment, work with the provider community to provide guidance on enrollment and process all applications expeditiously.

For additional information see the CMS Web site Internet-based PECOS Web page (www.cms.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.asp).