PECOS verification needed or HHAs may face false claims liability, nonpayment

There is a regulation that will go into effect July 6, 2010, that could impact your ability to continue service to as many as 20-40% of the patients that you serve. This includes current patients in need of continued care, as well as new patients referred on or after that date.

PECOS is the electronic database of physicians enrolled in or opted-out of Medicare. A large percentage of physicians who have valid NPIs and are licensed doctors of medicine, osteopathy and podiatric medicine, are not enrolled in PECOS.

It takes 60-90 days after enrollment in PECOS before the verification of the physician’s enrollment appears. Until there is a PECOS record, home health agencies are at risk that they are without authorization to bill Medicare, and that any claim for payment will be denied on prepayment or post-payment review.

Home health agencies that knowingly bill Medicare for services ordered by a physician that is not enrolled in PECOS (including billing for visits made after July 6th during an episode that started before that date) face the following consequences:

  1. False claims act liability
  2. Non-payment by Medicare for billed services

The new regulation at 42 CFR 424.507 (Learn more about 42 CFR424.507.) stipulates that, effective July 6, 2010, in order for a home health agency to receive payment for services to a Medicare beneficiary:

  • The Part A or Part B home health services must have been ordered by a physician;
  • A claim for home health services must contain the legal name and the National Provider Identifier (NPI) of the ordering physician, and
  • The ordering physician must have an approved enrollment record or a valid opt-out record in the Provider Enrollment, Chain and Ownership System (PECOS)

The regulation goes on to say, “A Medicare contractor will reject a claim from a provider or a supplier for covered services described in paragraphs (a) and (b) of this section [referring to Part B services and home health care] if the claim does not…” meet the requirements as set forth above.

Action to Take NOW and June 28-30th:

1)     Check Medicare’s database for your referring physicians’ NPIs.
Or check this website for PECOS physicians: OAandP.

  • Click on the zip file for the more user-friendly database.
  • Click on Find in the upper right hand corner of the Excel file and type in the NPI number. If the physician is not listed in the excel spreadsheet, then the physician is not enrolled.

Any claims for patients for which that physician has signed the POC are in danger of being denied. Contact that physician immediately to educate and inform them of the requirements.

2)            Call your Congressional Representative and Senators and follow up with an electronic letter

3)     Fax Notice Letters and call Your Referring Physicians and Discharge Planners to alert them of the July 6th PECOS Registration Deadline. (This is not needed for physicians that are found in the database.)

3)     Submit formal comments electronically to the CMS Interim Final Rule on PECOS

We urge you to contact your members of Congress by phone or email in accord with the following instructions:

1) Urge CMS to delay implementation of the rule requiring that physicians ordering home health care be enrolled in the PECOS data base. Further, CMS should hold harmless home health providers until such time as physicians have had a reasonable opportunity to enroll, and

2) Urge Congressional leaders to intervene with CMS to resolve this issue.  Let them know that this is an important issue for you and your state as patients otherwise eligible for Medicare services will be denied care.

3) Utilize the sample letters below to fax to physicians and discharge planners to inform them of the impact the rule will have on their patients and the services you provide. Then follow up with phone calls to encourage PECOS registration.

4) Finally, we urge every home health agency to submit formal comments to the CMS Interim Final Rule that contains these new requirements and the July 6th deadline. The notice can be found at this link.  Instructions for submitting comments can be found on page 24437.

This is a critical issue, and much of the above call to action information is from the Texas Association for Home Care and Hospice.

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One Comment to “PECOS verification needed or HHAs may face false claims liability, nonpayment”

  1. Hi Lisa,

    I have a question about the pecos. What happens if we have a patient we are already seeing and the physican at this time isn’t in the pecos system- but does register and say the date of registration isn’t until july 30th. We bill but will we get paid for the whole certification period or only for the visits done after july 30th when the physican enrolled?
    I have already gone to the NAHC website and sent letters to my cogressman/representatives and i urge all your readers to do the same. Not only does this affect our bottomlines, but more importantly the patients are affected by not being able to even recieve the homecare services that they need.
    thank you

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