Medicare announced yesterday, January 11th, that they will be continuing to delay the initiation of the ordering/referring provider edit. Originally they had announced that they would initiate an edit that would deny any claims with referring or ordering providers who were not entered into the PECOS system. The PECOS system, or Provider Enrollment, Chain, and Ownership System, is an online enrollment system that CMS implemented in late 2008. It gives providers the ability to enroll or update their application information online. CMS contractors have been inputting providers into the PECOS system since 2003. So any providers who have enrolled or made changes to their Medicare enrollment since 2003 are already in the PECOS system. Any providers who have been enrolled and have made no changes since before 2003 are most likely not in the PECOS system.
Originally CMS announced that all providers needed to be in the PECOS system by January of 2010. Any providers who refer patients to other providers or order tests or services for their patients must be enrolled or the services that they refer or order will be denied. The problem with this edit or denial is that the provider who will have their claim denied is not the provider who is not enrolled in PECOS. So they are penalizing the wrong people. For example, if a doctor refers a patient for physical therapy and the referring doctor is not in PECOS then the physical therapist’s services would be denied. Doesn’t seem fair to me.
Anyway, there have been several delays to this edit, and yesterday CMS announced it will be delayed yet again. They don’t give a clear reason for the delay but I believe they have received many complaints. Also, most carriers are very backlogged with enrollment applications which delays providers from getting entered into PECOS. Some carriers are still working on applications received in August. So many providers may have submitted the paperwork several months ago but still aren’t set. Doesn’t seem fair to reject claims because the carriers can’t keep up with all the applications. So, for the meantime, all are safe.
what is PECOS system?
PECOS stands for Provider Enrollment, Chain and Ownership System. It can be used in lieu of the Medicare enrollment application (i.e., paper CMS-855) to:
• Submit an initial Medicare enrollment application
• View or change your enrollment information
• Track your enrollment application through the web submission process
• Add or change a reassignment of benefits
• Submit changes to existing Medicare enrollment information
• Reactivate an existing enrollment record
• Withdraw from the Medicare Program
You may use the following link to access the site.
https://pecos.cms.hhs.gov/pecos/login.do