CMS Final Rule: HHAs Must Ensure Physician Enrollment in Medicare

The Centers for Medicare & Medicaid Services (CMS) in May 2010 published an interim final rule, with comment period, requiring submission of a National Provider Identifier (NPI) by physicians and eligible professionals who order and refer covered items and services for Medicare and Medicaid beneficiaries.

This rule required enrollment of physicians ordering home health and other services to be enrolled in the Provider Enrollment, Chain, and Ownership System (PECOS). The ordering and referring physician provisions became effective July 1, 2010 in accord with statutory requirements. However, home health services ordered by physicians not enrolled in PECOS have not been subject to claim rejections and denials to provide CMS with sufficient time to resolve problems with PECOS systems and to move all Medicare enrolled physicians from Legacy systems to PECOS. The delay provided time for CMS to develop systems to enable opt-out physicians, and physicians seeking to order and refer but not bill Medicare, to be enrolled in PECOS (i.e. VA, military physicians, etc.).

On Tuesday, the CMS posted for public inspection the final rule “Medicare and Medicaid Programs: Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreement” This final rule can be accessed by clicking here.

The final rule amended several provisions in the interim final rule. Language was amended in the final rule to clarify the enrollment requirement to mean enrollment in “Medicare-including PECOS or other Medicare enrollment systems.” Work is underway to transition all physicians enrolled in other systems, such as the Legacy system, to PECOS. This process is being expedited by CMS through physician Medicare revalidation. CMS stated that the enrollment to final approval status takes approximately 45 days, with a warning that physicians are not considered enrolled until applications reach the final approved status.

Specific provisions of this notice include:

  • Confirmation of the July 6, 2010 effective date for inclusion of the ordering physician’s NPI number on all claims billed by home health agencies to Medicare and Medicaid
  • Plans to develop and activate home health claims edits for legal names and NPI numbers physicians in Medicare enrollment records.
  • CMS will continue educational outreach to physicians and Medicare beneficiaries
  • Residents who hav3e an appropriate State license and are enrolled in Medicare (including enrolled via an 855O) may order and certify home health services.
  • Physicians that comply with the official opt out requirements will be entered in PECOS
  • Home health ordering and certifying physicians must be enrolled in Medicare, even in cases where there two different physicians perform each function.
  • Medicare enrollment would be based on the date that services begin and apply to both the RAP and final claim. However, Medicare will not deny payment for any portion of a full 60 days if the ordering physician were to terminate enrollment.
  • HHABNs are not to be used to notify patients when the reason for non-payment by Medicare is failure of the physician to be enrolled in Medicare.

CMS repeatedly reassures readers that they will give advance notice prior to turning on physician edits. CMS also stated that it does “not believe it would be prudent use of resources to pursue large-scale recoveries against claims with dates of service from July 2010 until such time as we activate prepayment edits that identify claims that do not have proper documentation of enrolled ordering and/or certifying suppliers” and “edits will apply to only those claims with a date of service on or after the date the edits are activated.”

At the same time, a CMS official, in a conversation with the National Association for Home Care & Hospice (NAHC), stated that this final rule serves as a notice of plans to activate home health claim edits for Medicare enrolled physicians, possibly as early as the effective date, which is 60 days after date of the publication in the Federal Register.

Home health agencies should immediately begin checking every physicians Medicare enrollment status in the Ordering and Referring Physician report. This report will continue to be available through the Ordering and Referring Reports on the CMS website. The reports will be updated weekly.

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