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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)

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