California HME Update
CMS Announces Editing the Ordering/Referring Provider in DMEPOS Claims Delayed

The Centers for Medicare & Medicaid Services (CMS) has delayed the implementation of Phase 2 of CMS CR 6421 for DMEPOS suppliers and CR 6417 for Part B providers until January 3, 2011.
 
The delay in implementing Phase 2 of these CRs will give physicians and non-physician practitioners who order or refer items or services for Medicare beneficiaries to other Medicare providers/suppliers sufficient time to enroll in Medicare or take the action necessary to establish a current enrollment record in Medicare prior to Phase 2 implementation.
 
As part of Phase 1 for CR 6421, CEDI implemented warning errors/edits to be returned on the CEDI GenResponse Report (GENRPT) if the referring/ordering provider submitted on the claim was not enrolled in PECOS and/or not eligible to order or refer services.
 
Should a DMEPOS supplier receive one of these warning errors/edits on a claim, CEDI recommends the following:
  • Contact the Ordering/Referring Provider to verify how their name is listed with their PECOS enrollment and ensure the name submitted on the claim matches the PECOS record.
  • Contact the Ordering/Referring Provider to verify their eligibility with PECOS.  
  • CMS has made available a file that contains the National Provider Identifier (NPI) and the name (last name, first name) of all physicians and non-physician practitioners who are of a type/specialty that is 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).  This file is downloadable from the Medicare provider/supplier enrollment Web site www.cms.hhs.gov/MedicareProviderSupEnroll, click on "OrderingReferringReport" on the left-hand side. This .pdf file contains approximately 800,000 records.  Due to the large size of this .pdf file CEDI suggests you right click and select "Save as" before attempting to open this file.
  • Verify the Type I (individual physician's) NPI and name of the Ordering/Referring Provider is submitted on the claim. If the Type II (physician's group) NPI and name is submitted, a match will not be found on the PECOS file.
For DMEPOS suppliers
  • CEDI validates the NPI, first four characters of the ordering/referring provider's last name and first one character of the ordering/referring provider's first name to perform the edits.
  • Verify the ordering/referring provider name is submitted on the electronic claims in all uppercase letters. 
  • Verify the name of the ordering/referring provider matches how the provider is enrolled in PECOS. 
  • Do include spaces in last names.  For example, if the ordering/referring provider's last name is A BCDE do not submit the last name as ABCDE
  • Do include special characters in last names.  For example, if the ordering/referring provider's last name is A-BCDE or A BCDE do not submit the last name as ABCDE
  • Do not use nicknames (BOB for ROBERT)
  • Do not use credentials (DR JOHN for JOHN)
  • Many ordering/referring providers are getting their enrollment information into PECOS or are updating their enrollment information.  It may take some time for a Medicare enrollment contractor to process these enrollment applications.  Once an application has been approved, the ordering/referring provider will have an enrollment record in PECOS that contains the NPI.  The CMS PECOS list will be updated periodically to include ordering/referring providers that have updated their enrollment information.
  • Upon implementation of Phase 2, only accept and fill orders from eligible Medicare providers. 
CMS continues to urge physicians and non-physician practitioners who are enrolled in Medicare but who have not updated their Medicare enrollment record since November 2003 to update their enrollment record now.  If these physicians and non-physician practitioners have no changes to their enrollment data, they need to submit an initial enrollment application which will establish a current enrollment record in PECOS.

 
Medi-Cal 10% Rate Cut Litigation

CAMPS has been working to get retroactive relief from the 10% Medi-Cal rate cut that occurred from July 1, 2009 to March 1, 2010. The federal court injunction that stopped the cut for some providers was upheld in the Court of Appeal and it seemed likely that the final order would also be expanded to include DME and supplies.

That negotiation has now stopped as  DHCS filed an a request for review by the US Supreme Court, which is the only appeal mechanism left in this process. The Supreme Court does not accept or agree to review many of the appeals that are presented, e.g. only about 10 % of the appeals. We are getting more information on the timing and impact of the DHCS filing but it will slow down any hope for relief for DME and medical supply providers.

 


 

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