NAHC Recommends CMS Develop a PECOS Crisis Management Plan
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.