PECOS deadline softened by CMS

Medicare will not start rejecting claims automatically on July 6 if the ordering or referring physician is absent from the enrollment system.

By David Glendinning — Posted July 2, 2010

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After numerous complaints from physicians about problems with Medicare's enrollment system, the Centers for Medicare & Medicaid Services on June 30 announced that it would launch a review of the Provider Enrollment, Chain and Ownership System, or PECOS.

As part of the review, CMS also said it would not automatically start rejecting physician claims for which the ordering or referring doctor is not properly enrolled in PECOS. The agency had moved up that deadline to July 6 from Jan. 3, 2011, for many types of Medicare services. CMS did not say when the automatic rejection process might start.

While the interim final regulation still will take effect on July 6, the enforcement delay means that claims for medical equipment, home health, imaging, laboratory and specialist services should process as usual for now, even if one of the physicians listed on the claim has not yet had a PECOS enrollment application processed successfully. CMS said that more than 800,000 physicians and others are now signed up properly, but some doctors have reported application backlogs and other system glitches that have prevented them from doing so.

The agency also plans to issue a final PECOS regulation after reviewing comments on the interim final rule. CMS indicated that the enforcement procedures it outlines in that final rule will take into effect any good-faith attempts that doctors have made to become compliant with the enrollment requirements.

The American Medical Association had called for CMS to push the July 6 deadline back to January 2011, in addition to stopping the automatic rejections process. The AMA complained that many doctors might see their claims rejected through no fault of their own if, for example, the referring physicians had not yet successfully filed PECOS applications.

But CMS said the July 6 compliance date was required by the national health system reform package approved by lawmakers, who want all physicians and other Medicare claimants enrolled in PECOS to prevent fraudulent claims from ineligible parties. Even though claims with enrollment discrepancies will not be rejected automatically, they will continue to come back with informational edits noting that PECOS issues must be resolved. CMS said it would implement a contingency plan to ensure that anyone listed on a claim without a proper enrollment record is an eligible professional.

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