Government

Medicare enrollment delays leave doctors out in the cold

A new database has slowed contractors' ability to process applications.

By Markian Hawryluk — Posted Feb. 23, 2004

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Washington -- Keith Davis, MD, is the only physician in the 1,200 square miles of Lincoln County, Idaho. His primary care practice in Shoshone is not even rural -- it's frontier.

So the family physician was thrilled in October to hire a locally born and raised physician assistant, Johnny Urrutia, to help care for his 5,000 patients. But four months later, Urrutia is still waiting to be approved by Medicare.

Although Urrutia has a billing number from his previous job, Idaho's Medicare contractor has yet to issue a number he can use from the Shoshone office.

"It just seems kind of strange that it should take so long to get a number for somebody who's in the system already," Dr. Davis said. "It really creates a cash flow issue when you have Medicare patients coming in. He can see them, but we can't bill for it."

Dr. Davis and Urrutia are not alone in their quandary. Nationwide, physicians and others participating in Medicare Part B have run into lengthy delays in getting new enrollment applications or even simple address changes processed since the Centers for Medicare & Medicaid Services implemented a new enrollment database in November 2003.

"It's not an isolated issue," said Justine Handelman, executive Washington director for the BlueCross BlueShield Assn. "If you talk with any of our carriers, they've been experiencing the same problem."

Each Part B carrier had previously operated its own enrollment program with unique decision-making rules. There was no centralized depository of information on physicians enrolled in Medicare and no way of sharing information between carriers.

So CMS implemented the Provider Enrollment Chain and Ownership System, a centralized database into which fiscal intermediaries and Part B carriers enter enrollment data. The system was launched among fiscal intermediaries in July 2002 and then rolled out to the carriers last fall.

Because carriers process about 600,000 applications each year, the added volume swamped PECOS.

"The system has been unstable," said Lana Finch, Part B operations team leader for Blue Cross and Blue Shield of Montana. "There were some weeks when we hardly had any up-time."

From Nov. 3, 2003, through Jan. 27, the system was down for 11 of the 54 business days. CMS officials have been working with the vendor that developed the PECOS software and had stabilized the database as of the last week of January. Finch said access to the system has improved "immensely," but carriers must now work through the massive backlog.

"There are also some learning problems here," Finch said. "The staff is still kind of in a trial-and-error learning curve. If they don't do everything exactly right, they get errors and they have to go back, and that extends the processing time."

Carriers indicate that processing times for each application have more than doubled from two or three days under the old system to at least six days under PECOS. Finch said the new system's biggest handicap is that CMS chose not to accept the physician records that contractors had in their old systems. As a result, adding new physicians to existing practices or making changes to existing enrollment data involves re-entering all of the practice's information.

The agency is reconsidering that decision, said Tim Hill, acting director of CMS' Office of Financial Management and chief financial officer.

Some states hit really hard

About 86% of new applications are being processed within the 60-day time frame allotted, Hill said. CMS expects to reach its goal of 90% by April. But Hill acknowledged that some carriers are handling the transition much better than others.

"When you look at a pre-PECOS workload, some are below where they were, and others are significantly below where they were," he said.

The problem is most acute in areas of New York served by Empire Medicare Services. Physicians have reported waits for approval of nine to 12 months -- even before PECOS was implemented.

CMS is looking at Empire's processes to gauge whether it's making the most efficient use of its resources. Empire declined to comment.

According to Ted Strange, MD, a geriatrician who runs a residency program at the Staten Island University Hospital, the delays are creating a huge burden for groups and facilities adding new physicians.

"They're literally being the bank, footing the bill, and waiting for hopefully at some point in time the ability to bill for these services and recoup the money," he said. "Here we've passed the most comprehensive Medicare bill in the country since the 1965 Medicare and Medicaid Act ... but we can't get young physicians their numbers so as to provide care."

Carriers have been diverting staff from other functions to help with the backlog but are somewhat limited by financial constraints. BCBS' Handelman said CMS had been unable to grant supplemental funding requests because the government had been operating at 2003 budget levels. Anticipating the transition to PECOS, the Bush administration had earmarked additional funds for contractors in fiscal year 2004, but those were not available until Congress approved appropriations levels in late January.

The AMA is working on the problem. "Our goal is to have this issue resolved before CMS moves to re-enroll the entire physician community later this year in preparation for transition to the national provider identifier number," said Trustee Joseph M. Heyman, MD.

The contractors have come up with a list of possible solutions to be discussed with CMS. Agency officials are sending teams to help carriers with the transition.

"We are not ignorant that in some places in particular there's a very acute issue, and we are working hard to make sure we get these issues resolved as quickly as we can," Hill said.

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