Medicare Enrollment Update for Referring Ordering Physicians: PECOS

June 3, 2010

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New regulations stemming from the Affordable Care Act mandate that any physician who refers or orders services (DMEPOS, home health, 'specialist services' [as yet undefined by CMS], lab services, or imaging services) will need to be enrolled with Medicare in the Provider Enrollment, Chain and Ownership System (PECOS) database by July 6, 2010. This includes any physician who has not submitted an updated enrollment application to Medicare in the past 6 years or has had a change to their enrollment information during this time but has not reported the change. If physicians are not enrolled by July 6, the physicians who they refer patients to (and thus must list the name and NPI of the physician they referred/ordered) could see their claims rejected. The regulation actually goes beyond what is in the new health system reform law which says that only physicians who order or refer home health and DMEPOS must be enrolled by July 1.

The AMA and many other specialty societies—including the AAN—are submitting comments to CMS opposing the new regulations. Specifically, we believe CMS should limit the July 6 date to what is required by the law: orders and referrals for home health and DMEPOS only. Physicians who order or refer for all other services should be permitted to have until January 3, 2011 to enroll.  

Also under the new CMS policy, physicians who have opted-out of Medicare will not be required to enroll in PECOS, but they must have the correct paperwork filed with CMS indicating their status. CMS is likely to propose a specific new form for opt out physicians soon. Until then, physicians who have never enrolled in the Medicare program and wish to opt out of Medicare must provide their carrier with a National Provider Identifier (NPI). The carrier must annotate its in-house provider file that the physician has opted out of the program; and the physicians must not receive payment during the opt-out period (except in the case of emergency or urgent care services). At a minimum, physicians who have opted-out should call their contractor to check and see if they are listed as such.

Though the AAN is working to get the July 6, 2010 date pushed back to January 3, 2011 for physicians that order or refer specialist, lab, or imaging services, physicians should make sure that you are ready for the accelerated compliance date of July 6 to ensure that you avoid any potential denials.

Click here or use the link below to access the relevant regulations that stemmed from the Affordable Care Act.

For more information on PECOS and how to enroll, visit the CMS PECOS website.