According to the CMS Web site, PECOS can be an effective fraud-fighting tool.
“PECOS helps to ensure Medicare works only with reputable business partners,” the Web site stated. “As a national enrollment database, PECOS significantly enhances fraud and abuse prevention and enforcement activities since it allows CMS and enrollment MC (Medicare contractor) to view all Medicare activity of a particular p/s (provider and supplier). Fraud investigators have a complete national picture of a provider and its managers and owners, allowing them to check for patterns of fraud that cross providers and/or contractor jurisdictions.”
According to Donna Andrew, the Marshfield Clinic's director of patient financial services, it is still a work in progress. She said if a different form of a physician's name is used on the claim—such as a shortened first name or if a middle initial is used—than appears in the PECOS database, the claim could be denied.
Andrew said the new policy has led to Marshfield cross-checking to make sure that the names of its 800 physicians and the names of the multitude of doctors in its referral base match the name stored in PECOS.
“We were struggling for the last two weeks with how we would be able to do this by Jan. 4,” Andrew said. “We get a lot of referrals from outside groups, and—if they haven't taken the initiative to be certified or made sure their information is correct—it would be denied.”
The new implementation date is April 5, and Andrew said that should give Marshfield sufficient time to prepare. Brent Miller, Marshfield's federal government relations director, credited the AMA and the Medical Group Management Association for sounding the alert on the PECOS policy, and said it also validated his compulsion of carefully slogging through the deluge of e-mails he receives each day—as this habit resulted in Marshfield being the only provider to join the effort.
“We are very happy they ID'd the problem,” Miller said of the e-mail alert he received from the AMA. “It seemed pertinent to me, and Donna verified my hunch.”
The CMS announced the new implementation date in a Nov. 23 e-mail.
“A physician or nonphysician practitioner who orders or refers and who does not have a current enrollment record that contains the NPI (National Provider Identifier) will cause the claim submitted by the Part B provider/supplier who furnished the order or referred item or service to be rejected,” the CMS' Nov. 23 e-mail stated. “CMS continues to urge physicians and nonphysician practitioners who are enrolled in Medicare but who have not updated their Medicare enrollment record since November 2003 to update their enrollment record now.”
In an e-mailed statement attributed to its president, J. James Rohack, the AMA noted that it still had concerns.
"The extension from January to April is helpful as it will provide more time to conduct the necessary outreach to physicians to alert them to this new policy,” the e-mail said. “The AMA remains concerned however that this remains an insufficient amount of time to get all the physicians into PECOS who need to re-enroll, ensure that all Medicare contractors are able to adequately absorb this new work, prevent enrollment backlogs and avoid claims processing interruptions."
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