Medicare Denying Payments Due to Enrollment

As of January 6, 2014 as part of the Affordable Care Act, Medicare will deny payment to Home Health Agencies, Imaging services, Durable Medical Equipment Providers and clinical laboratories for referred tests if the referring doctor is not listed in the PECOS system.  Doesn’t seem fair does it?  Seems like they are penalizing the wrong provider.

Why did this happen?  Since 2009 the AMA has strongly advocated to Medicare that it require the ordering and referring physicians to enroll or verify enrollment in Medicare through the PECOS online enrollment system. In 2010 Congress passed a law requiring physicians who order or refer testing for Medicare patients to enroll in Medicare and use their NPI numbers on such claims.

The Internet-based Provider Enrollment, Chain and Ownership System enables providers to submit an initial Medicare enrollment application, view or change their enrollment information,
track their enrollment application through the web submission process, add or change a reassignment of benefits, submit changes to existing Medicare enrollment information, reactivate an existing enrollment record, withdraw from the Medicare Program or
submit a change of ownership (CHOW) of the Medicare-enrolled provider.

CMS has now published a final rule on these requirements.  This new rule affects

  • Imaging or lab services, home health agencies, and DME suppliers
  • referring doctors of these services
  • medical billing services

The imaging centers, laboratories, home health services and DME suppliers will be affected by non-payment of services referred by the non-compliant providers.  If providers who are not enrolled in PECOS refer Medicare patients to them for testing or services, claims for those services will be denied .

The non-compliant referring doctors will be affected by the irate providers who are not being paid because the referring doctor was non-compliant.  They will be forced to comply or these facilities will refuse to service their patients.

The medical billing services will be affected by the marketing opportunity this presents.  Medical billing services can go to the PECOS website to see who is not compliant and then approach them about how they can help with this problem.

For a list of who is registered in PECOS click here

If you need to register with PECOS, it is not necessary to complete your application online. 

The 855I paper application form can be completed in place of the online PECOS application.  If a paper application form has been completed within the last few years the applicant will already be listed on the PECOS site.


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