• CMS giveth and Congress taketh away

    In March (see "CMS extends cease fire on referring/ordering edits" on March 17), I reported that the Centers for Medicare & Medicaid Services (CMS) had extended the delay in implementation of new rules that give Medicare the authority to reject claims for services or supplies when the ordering physician or health care professional is not enrolled in the Medicare Provider Enrollment, Chain, and Ownership System, or PECOS. The agency had announced a delay in implementation of the new policy until Jan. 3, 2011. 

    Unfortunately, what CMS gave, Congress and the President took away with passage of the Patient Protection and Affordable Care Act (PPACA). Amendments made by PPACA essentially mandate implementation of the new rules effective July 1, 2010. 

    Or at least that is CMS's interpretation of the statute. CMS published an interim final rule with comment period in the Federal Register on May 5, 2010. The interim final rule implements several PPACA provisions that impact provider and supplier enrollment, ordering and referring, and documentation requirements.  CMS is accepting comments on the interim final rule through July 6, 2010. 

    Related to the referring and ordering issue, CMS states that, effective July 1, 2010, it is requiring Medicare contractors to reject claims for selected items and services that are ordered or referred if the legal name(s) and national provider identifier(s) of the ordering/referring provider(s) are not on the claim or the ordering/referring provider does not have an approved enrollment record in PECOS. Affected items and services include durable medical equipment, prosthetics, orthotics, and supplies; home health items or services; and laboratory, imaging, and specialist services, where applicable. CMS is considering extending the provision to prescribed Part B drugs next year. 

    CMS has provided an exception to the requirement that the referring/ordering provider have an approved enrollment record in PECOS in the case of an ordering/referring provider who has opted out of Medicare. Apparently, even CMS thought it was ludicrous to require someone to enroll in Medicare for purposes of ordering and referring when they had already opted out of Medicare for everything else.

    What makes this particular provision so maddening is the difficulty so many physicians and others have actually enrolling through PECOS. Not only is it cumbersome, but it can often take months, and even making a simple address change through PECOS can lead to enormous headaches, based on some of the horror stories that I have heard.

    For those that are interested, CMS is hosting a national provider and supplier conference call on Wed., May 19, from 3 to 5 p.m. ET. The focus of the call will be the interim final rule noted above. To participate, all you have to do is dial 1-800-603-1774 and reference Conference ID 61448973.  It may not change anything, but at least it's an opportunity to learn more on the subject and make your voice heard in the process.

    Posted on May 18, 2010 by Kent Moore

    Disclaimer: The opinions and views expressed here are those of the authors and do not necessarily represent or reflect the opinions and views of the American Academy of Family Physicians. This blog is not intended to provide medical, financial, or legal advice. Some payers may not agree with the advice given. This is not a substitute for current CPT and ICD-9 manuals and payer policies. All comments are moderated and will be removed if they violate our Terms of Use.