Click here for free PECOS physician lookup

On July 6, 2010 a regulation will go into effect 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.

The new regulation at 42 CFR 424.507 stipulates that, effective July 6, 2010, in order for a home health agency to receive payment for services to a Medicare beneficiary:

• 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)

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. According to audits conducted by home health agencies, anywhere between 24-40% of their ordering physicians did not meet the new PECOS enrollment requirements

PECOS enrollment takes 60-90 days before the verification of the physician’s enrollment appears in PECOS. 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.

Therefore, 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

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

Call your Senators and Representative in Congress to ask that they:

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.

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.

The National Association for Home Care (NAHC) is working on this issue in order to have a common voice for the home care industry on this situation.  NAHC has provided some sample letters to physicians and discharge planners that you may use to inform them of the impact the rule will have on their patients and the services you provide.

• Click here for the physician letter
• Click here for the letter to discharge planners

All of this information and any new information will be posted on our website for agencies to use and to keep you informed.  Please check back regularly for any new postings and any new information.

Below are some additional steps that you can take immediately to mitigate the impact of the interim final regulation regarding physician enrollment:

PHYSICIAN ENROLLMENT VERIFICATION & NOTIFICATION

• Validate PECOS enrollment for all current ordering physicians against the CMS web site at this link.
• Contact physicians whose enrollment you are unable to confirm to:
  • Verify the physician’s legal name
  • Verify the correct NPI number
  • Request a copy of any confirmation of PECOS enrollment that the physician has received from CMS and accept that as proof of PECOS enrollment
• Inform non-enrolled physicians of:
  • The new regulation and the need to enroll in PECOS
  • Your inability to provide services under Medicare for their patients until the physician’s enrollment is verified in PECOS

REFERRAL SOURCE NOTIFICATION

• Advise all referral sources, including hospitals, of the new regulation and your inability to provide services under Medicare for patients of physicians not enrolled in PECOS

BENEFICIARY NOTIFICATION

• Inform all patients of physicians not enrolled in PECOS of your inability to bill Medicare for their services and their financial liability for any care provided
• Provide patients of non-enrolled physicians with a Medicare Expedited Determination Notice and an HHABN prior to any service termination
• Ensure that you are compliant with agency policies and State law regarding patient notification prior to termination of services.

Some of this information was culled from the  Texas Association for Home Care and Hospice (TAHC&C)

Click here for free PECOS physician lookup

Effective January 1, 2010, for calendar year 2010, the outlier payments made to each Home Health Agency (HHA) will be subject to an annual limitation. Medicare systems will ensure that outlier payments comprise no more than 10% of the HHA’s total HH PPS payments for the year. Medicare systems will track both the total amount of HH PPS payments that each HHA has received and the total amount of outlier payments that each HHA has received. When each HH PPS claim is processed, Medicare systems will compare these two amounts and determine whether the 10% has currently been met. If the limitation has not yet been met, any outlier amount will be paid normally. (Partial outlier payments will not be made. Only if the entire outlier payment on the claim does not result in the limitation being met, will outlier payments be made for a particular claim.) If the limitation has been met or would be exceeded by the outlier amount calculated for the current claim, other HH PPS amounts for the episode will be paid but any outlier amount will not be paid. When the calculated outlier amount is not paid, HHAs will be alerted to this by the presence of claim adjustment reason code 45 on the accompanying remittance advice. This code is defined: “Charge exceeds fee schedule/maximum allowable or contracted/legislated fee arrangement.”

Since the payment of subsequent claims may change whether an HHA has exceeded the limitation over the course of the timely filing period, Medicare systems will conduct a quarterly reconciliation process. All claims where an outlier amount was calculated but not paid when the claim was initially processed will be reprocessed to determine whether the outlier has become payable. If the outlier can be paid, the claim will be adjusted to increase the payment by the outlier amount.

These adjustments will appear on the HHA’s remittance advice with a type of bill code that indicates a contractor-initiated adjustment (type of bill 3XI) and the coding that typically identifies outlier payments. quarterly reconciliation process occurs four times per year, in February, May, August and November.

If you need additional information regarding the CMS rule, you may visit the CMS website at: http://www.cms.hhs.gov/center/hha.asp

On January 12, 2010, a 7.0 earthquake ravaged the small island nation of Haiti near the capital of Port-Au-Prince, affecting up to what some estimate to be a third of their population.  Many have been left homeless, and there are food and water shortages.  Aid is needed immediately for the recovery of this nation which has historically already faced so much poverty and adversity. Once recovery has begun, aid will also be needed to re-establish an infrastructure, and to rebuild homes, schools and hospitals. We here at AXXESS encourage your donation to aid in the Haiti relief effort and have provided a link that will allow your gift to go directly to the Red Cross.  Your gift will help insure that life-saving supplies – including food, clean water, blankets, and tents — are distributed to children and families devastated by the earthquake and aftershocks in Haiti. Please, have a heart for Haiti, and donate now.

External Link:

Donate Here

Is it your dream to own a Home Health Agency or open a new branch of an existing agency, but you do not know where to start? You do not need to look any further. We have successfully guided several agencies across the country through the Joint Commission (JCAHO), CHAP or ACHC accreditation and obtain Medicare certification. We make it easy. Call today.

Learn More at: http://axxessconsult.com/our-services/startup-services/

or call  (866) 795-5990

There has been an unprecedented growth in the home healthcare industry that can be attributed to an increasing elderly population, growth in chronic disease prevalence, physician acceptance of homecare, medical advancements and the continued movement towards cost-efficient treatment options from both public and private payors. Therefore your decision to own a Home Health agency now is timely.

Several studies have concluded that the home healthcare market provides an attractive investment opportunity over other investment opportunities. Based on a report from the Centers for Medicare and Medicaid Services, national expenditures on home healthcare services are projected to reach more than $90 billion by 2014. In 2003 home healthcare was the fastest growth area for national healthcare spending, behind only prescription drugs. Expectations are that home healthcare spending will eventually overtake prescription drug growth. Research shows that this demographic shift is due to the increase in average life expectancy, as well as the baby boomer generation becoming senior citizens. Therefore, as the U.S population gets older, the need for home healthcare services will continue to grow.

Learn More at: http://axxessconsult.com/our-services/startup-services/

or call  (866) 795-5990