NAHC Recommends CMS Develop a PECOS Crisis Management Plan
December 30, 2013 12:12 PM
On January 6, 2014, the Centers for Medicare and Medicaid Services (CMS) will trigger a home health services claims edit that will deny any claim where the certifying physician is not enrolled in Medicare. This action comes more than three years after the Affordable Care Act banned payment of any claim that did not involve a duly enrolled physician. The delays in implementation were due to a combination of CMS system problems and the slow speed of physician enrollment.
During those delays, CMS has done everything possible to facilitate physician enrollment. Likewise, the home health community has tried to assist physicians nationwide to understand the need for them to enroll. Great progress in that regard has been made. However, it appears that for whatever reason, the physicians have not fully complied. The VA physicians are particularly deficient - apparently because they still, mistakenly, believe that they do not need to enroll as they are not paid by Medicare for physician services.
To address problems that are expected to surface, NAHC recommended that CMS put in place a communication process to deal with the inevitable fallout that will start in January. While it is hoped that the problems will be limited in number, there is a near guarantee that there will be some. Home health agencies will have three bad choices when receiving care orders from a non-enrolled physician. First, they can accept the orders and provide care with neither Medicare reimbursement nor the ability to charge the patient. Second, they can deny admission to the patient. Third, they can help the patient find a new physician who is Medicare enrolled. In these circumstances, the treating physician may finally take steps to enroll, but enrollment would not be effective for several weeks.
NAHC suggested to CMS that it set up a hotline or other communication approach that involved parties can use when the concerns arise. Home health agencies should not be criticized for the failure of physicians to take the simple steps necessary to enroll. CMS is certainly not blameworthy in any respect. Patients should not be relegated to confusion. Physicians may respond appropriately if the communication on enrollment responsibilities comes from Medicare rather than a home health agency. A hotline for physicians and patients will provide a way for CMS to gauge the extent of the problems facing stakeholders and to provide tailored guidance to those calling.
NAHC recommends that agencies develop their own crisis management plans to deal with affected patients. Those plans should include a list of alternative physicians, prepared communications to patients explaining the cause for a rejected admission, and a communique to affected physicians directing them to the enrollment process for future patient referrals.
NAHC will be tracking the impact of the January 6 physician enrollment edits. Agencies are encouraged to convey their experiences to NAHC in order to improve the possibilities of further short-term relief from the requirement.