Recently the interim final rule regarding the need for health care professionals and physicians ordering or referring patients for services or covered items to enroll in the National Provider Identifiers [NPIs] process was released. While at first glance the health care professional and physician enrollment requirement might not appear to be of concern to DMEPOS, home health and hospice providers, it does in fact impact their claims submission and billing process.
The interim final rule, published in a recent Federal Register, has a number of problematic areas, including the expansion of the NPI to Medicaid providers’ requirements for claims submissions. Potential problems include application process delays and rework, as well as other requirements of concern to DMEPOS and Home Health Agency [HHA] providers. These providers will be required to include in their submitted claims both the physician and/or health care professional’s legal name and NPI number and to verify that the physician or eligible professional have either an approved enrollment record or a verified valid opt-out record in the Provider Enrollment, Chain, and Ownership System (PECOS). In addition, the interim final rule requires DMEPOS and HHA providers, seeking to remain actively enrolled in Medicare and Medicaid to retain, for a minimum of seven years from the date of service, specific documentation regarding this verification process. Documentation must contain the NPI number of the physician or the eligible professional who ordered or referred the patient for services or equipment. Should a HHA or DMEPOS fail to do so and be unable to provide proof of this documentation, their Medicare and Medicaid enrollment is subject to revocation for up to one year per infraction.
Data between the Fiscal Intermediary Standard System (FISS) provider billed claim to that of a national PECOS file and the Medicare claims systems will also be compared to determine that accurate and complete information has been provided. CMS has outlined a two-phase implementation approach. During Phase 1 a Remittance Advice [RA] will be issued requesting the required missing claims data. However during Phase 2, the claim will be rejected. In order that billing can be submitted and paid, HHA and DMEPOS providers are cautioned to prepare a new process now that includes a data match or NPI verification being made at the time of referral in order to finalize its claim submissions.
A process revision to the current physician verification licensure is suggested that includes requesting the NPI for all physicians and/or health care professionals referring patients for services, as well as verification of the exact spelling and full name of the physician according to his or her Medicare enrollment. An online resource for verification of physician enrollment is available through an Internet PECOS website link at http://www.cms.gov/MedicareProviderSupEnroll/04_InternetbasedPECOS.asp.
HHA and DMEPOS providers are further advised to directly contact any physicians and/or health care professional that they are not able to locate in PECOS, in order to obtain the following information, [1] the individual’s name, as enrolled in Medicare, [2] the Medicare enrollment number, and [3] the NPI enrollment number. Should referring physicians/health care professionals be unable to provide this information, providers should clarify [1] if the physician/professional has opted out of Medicare, [2] if the physician/professional is aware of the need to obtain an NPI, [3] if or when the physician/professional plans to obtain his NPI, and [4] that the provider will be unable to provide services, under Medicare, if the physician/professional is unable to provide his NPI. This process can and should be integrated into the existing ongoing physician/professionl licensure verification process.
At this time there are concerns over the accuracy of the PECOS System, as well as the myriad of implementation dates being presented. Concerns that accurate information can be obtained when needed have been posed, and still need to be addressed, in order that care access is not affected. In order not to experience claims denials and potential cash flow problems at the time of full implementation, providers are cautioned to remain knowledgeable of this rule’s final interpretations, and to clarify concerns and questions with CMS prior to the final implementation dates. |
