PECOS Confusion: Who Has to Enroll? Don't Ask

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Medical Economics Feature - June 2010

Tex Med. 2010;106(6):49-53.


By Ken Ortolon
Senior Editor

Do you or don't you? No one seems to know quite yet.

When Medicare launched its Provider Enrollment, Chain, and Ownership System (PECOS) in November 2003, the idea was to get all physician and nonphysician health care professionals who bill Medicare enrolled in one national database.

But nearly seven years after introducing PECOS, officials say about 25 percent of U.S. Medicare physicians and other health care professionals still are not enrolled. Essentially, physicians already enrolled in Medicare when the PECOS system debuted who haven't changed their enrollment information since then were not required to reenroll through the PECOS system.

Because of conflicting reports, many physicians are asking, Who must enroll in PECOS by January to have their claims paid - all physicians who treat Medicare patients or only physicians who order durable medical equipment (DME) for their Medicare patients?

Texas Medicine  could not get an answer to that question.

Communicating only by e-mail, Peter Ashkenaz, Centers for Medicare & Medicaid Services (CMS) spokesperson, said all physicians "should" enroll in PECOS by Jan. 3, 2011. However, he also wrote that all physicians "must have a current enrollment record" to order or refer services in the Medicare program.

Pressed for a simple yes or no answer to whether all physicians must be in PECOS to continue being paid by Medicare, Mr. Ashkenaz replied that "there is no simple yes or no because we will be issuing an implementing regulation later in the year. That will explain the details."

Adding to the confusion is that TrailBlazer Health Enterprises, the Texas Medicare contractor, says it will process claims submitted by any physician whose name is in its internal enrollment system, even if he or she is not enrolled in PECOS.

Some Texas physicians complain CMS did a poor job publicizing PECOS, which led to the confusion over enrollment. Plus, even physicians who have tried to sign up for PECOS say its online enrollment website, which is supposed to make registering easy, does not do so.

"The quick and easy online application system took only about two-and-a-half hours of my wife's and office manager's time," said Corpus Christi ophthalmologist Jerry Hunsaker, MD. "Two-and-a-half hours with me doing it would be understandable, but my wife [former TMA Alliance President Keely Hunsaker, DDS] is very savvy and used to dealing with applications like this, and so is my office manager."

What's more, numerous Texas physicians are concerned about CMS requiring physicians who enroll in Medicare through PECOS to be paid through electronic funds transfer (EFT). While they are uncomfortable giving the government access to their bank account information, it appears they have little alternative.

Going National

Before PECOS, each regional Medicare contractor maintained its own enrollment database.

Wanda Shea, director of provider enrollment for TrailBlazer, says setting up a national provider database is closely tied to federal efforts to promote electronic health records.

"The electronic health records initiative is believed to be based on information that's in PECOS," Ms. Shea said. "So it would be in the provider's best interest to be in PECOS."

She adds that PECOS is intended to give CMS and the various regional Medicare contractors one "full, comprehensive listing of provider records."

But TMA officials say the process of getting physicians and other health care professionals already enrolled as Medicare providers into PECOS has been slow because Medicare has no electronic process to connect the various contractors' existing enrollment systems to PECOS. Consequently, PECOS captured only newly enrolled Medicare providers and those who changed their enrollment information, such as new practice locations.

Ms. Shea says PECOS provider enrollment stands at about 80 percent for the TrailBlazer region, slightly higher than the national average.

CMS first set the PECOS enrollment deadline at January 2010, then April, and then Jan. 3, 2011.

Agency officials say the delays were intended to give physicians and other health care professionals who order items or services or who refer Medicare beneficiaries to other providers or suppliers sufficient time to enroll.

Ms. Shea says TrailBlazer also submitted a plan to CMS to help facilitate enrollment by soliciting reenrollment applications from those not currently in PECOS.

If approved by CMS, TrailBlazer will solicit applications from about 10 percent of the providers not in PECOS each month for a year.

Not So Fast

As noted, there is much confusion over who is covered by the January 2011 deadline. Dr. Hunsaker is not certain if he qualifies as a physician who orders DME. Medicare covers the first pair of eyeglasses for patients following cataract surgery, but Dr. Hunsaker has been unable to verify if those glasses fall under the DME rules.

Texas Medicine asked CMS officials about that and was referred to the National Supplier Clearinghouse website. A search of that website failed to turn up an answer, but TMA experts say eyeglasses do fall under DME, and physicians who order them would need to be enrolled in PECOS.

There also appears to be confusion as to whether the PECOS enrollment requirement applies to any physician who refers a patient to another provider or only in instances where the ultimate payer for those services is someone other than the regional Medicare contractor.

Even Slower

About a year ago, CMS set up a PECOS enrollment system online that was supposed to facilitate enrollment in the system.

But TMA's Payment Advocacy Department staff says Dr. Hunsaker is not the only physician to have problems with the "quick and easy" online enrollment system. Other physicians told the staff the online system is a major hassle.

"When it first rolled out, there were tons of issues with it," said Erin Gregorcyk, TMA payment specialist. "The system was crashing. We heard from a lot of physicians that the screen would freeze or take forever to load. And when the screen freezes, they have to go back in and start all over."

Abilene otolaryngologist Austin King, MD, was among the physicians who encountered those problems.

"Supposedly you could enroll online," Dr. King said. "But I and many other physicians found the thing would just kick you off. You'd put in a bunch of information, you'd think it would be right, and then you had to start over again."

Mr. Ashkenaz says security measures CMS built into the system could be part of the problem. If the user does not enter data within 15 minutes, his or her session automatically ends, he says. While the online enrollment system is undergoing some changes, it is unclear whether that issue is being addressed.

CMS encourages physicians, nonphysician practitioners, and their designees to review the document titled, "Internet-based PECOS - Getting Started Guide for Physicians and Non-Physician Practitioners" [PDF] before using Internet-based PECOS.

Ms. Shea says physicians do not have to use the online tool when enrolling in PECOS. They may still send a paper application to TrailBlazer, which will enter the necessary information into the PECOS system, she says.

Physicians have encountered other hassles with PECOS enrollment. Weslaco internist Leticia Volpe, MD, attempted to apply for PECOS and found "you have to revalidate everything you've ever done in your life."

When she submitted her PECOS application, Dr. Volpe found she did not have the right type of National Provider Identifier for her practice and had to apply for both that and new Medicare and Medicaid numbers. As a result of several snafus with that process, she has been unable to bill Medicare since January.

The problem left Dr. Volpe with weeks of unpaid Medicare claims and seriously compromised the cash flow in her practice.

"I basically have a geriatric practice," she said. "Medicare is about 80 percent of my practice."

Dr. King also complained that the 10- to 12-page PECOS enrollment application asks for a lot of information that "goes far beyond what Medicare needs to have. I think they're using this as a means to gather information about practicing physicians."

Physicians are required to provide the physical site where all old medical records are stored if stored off site and names and Social Security numbers of all employees empowered to make any decisions for the practice.

"You also have to sign a form stating that they've never been convicted of a financial crime," Dr. King said.

Electronic Banking, Not

Dr. Hunsaker says he thought he had enrolled successfully in PECOS only to be notified that his application was incomplete because he had not provided the necessary bank account information to enable Medicare to pay his claims via EFT.

As far as Dr. Hunsaker is concerned, that application will stay incomplete because he has no intention of giving CMS or anyone else that information.

"I don't like anyone having access to my bank accounts electronically because if you can put something in electronically, somebody can figure out how to take something out," he said.

Dr. Hunsaker says EFT also would disrupt accounting processing within his practice.

"We get the explanation of benefits and we don't deposit the check until we have posted it to each patient's account and explained where the money came from and made sure that there's not a mistake," he said.

Dr. King also complained that physicians who have loans with the bank where their EFT payments are deposited must submit a letter from their banker stating that no Medicare funds will be used to offset those loans.

"That's the most bizarre thing I've ever heard of," he said. "When the money is deposited in your account then I've always assumed that that's your money. You can go to Las Vegas and gamble with it if you want to."

Dr. Hunsaker and other physicians have little choice but to get paid electronically, whether or not they enroll in PECOS. CMS officials say a rule adopted in June 2008 requires providers and suppliers to receive payments via EFT. They say the change will reduce paperwork and cut administrative costs.

"Moreover, we believe that the transition to EFT will help ensure that payments are made to the provider or supplier of services," Mr. Ashkenaz said. "Finally, in a national disaster, such as Hurricane Katrina, providers and suppliers using EFT would be ensured a continuity of payment."

Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by e-mail at  Ken Ortolon.


Verify Your PECOS Enrollment Online, Via Telephone

Are you unsure whether you are in Medicare's Physician Enrollment, Chain, and Ownership System (PECOS)? There are now two ways to verify if you are in the PECOS system.

  • Go to the Medicare provider/supplier enrollment website and click on "Ordering/Referring Report." The file contains the National Provider Identifier (NPI) and the name (last name, first name) of all physicians and nonphysician practitioners who are eligible to order and refer in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS that contain an NPI).
  • Or, call TrailBlazer's   Interactive Voice Response (IVR) system at (877) 567-9230. From the Part B main menu, the caller can check his or her NPI status in PECOS by pressing 7. The caller will be prompted to enter their NPI. The IVR will repeat the NPI entered to allow the caller to confirm if correct. The IVR will inform the caller if his or her NPI is in PECOS. If it is not, the IVR will direct the caller to contact Provider Enrollment customer service.

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