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PECOS data to aid CMS payment review

September 19, 2014

By Kelly Soderlund

The Centers for Medicare & Medicaid Services is creating a computer matching program that it claims will make it easier to confirm that health care providers, including dentists, are eligible to receive reimbursements.

The program, created in partnership between CMS' Center for Program Integrity and the Department of Treasury's Bureau of the Fiscal Service, is intended to reduce waste, fraud and abuse. The matching program will ensure that payments are directed to properly enrolled health care providers and that no claims are submitted on behalf of providers who are deceased or otherwise unqualified to receive reimbursements, according to CMS. It will also assist federal and state governments in collecting monies to be refunded because of overpayments and fraudulent claims.

In 2009, the agency announced a plan to alert providers of incorrect, missing, or invalid information. Earlier this year, CMS started denying claims submitted by providers who did not have current Medicare enrollment records or who had missing, incomplete or invalid information in the Provider Enrollment, Chain and Ownership System.

Effective June 1, 2015, dentists who treat Medicare eligible patients must either enroll in the program through PECOS or opt out in order to prescribe medication to their qualifying patients with Part D drug plans.

"This requirement does not take into account the extremely low probability of fraud involved in the routine prescriptions written for Medicare Part D patients by dentists," said Dr. Kevin Sessa, chair of the ADA Council on Dental Practice. "The ADA met with the ombudsman of the Small Business Administration to request assistance in fighting this unnecessary and burdensome rule and is supporting congressional legislation that gives elected officials greater control in preventing rules that hinder management of dental practices for little or no obvious purpose.

If this rule is not reversed, Medicare eligible patients will be denied prescription drug coverage for any prescriptions written unless the dentist:

  • Enroll as a Medicare provider;
  • Opt-out of the Medicare program;
  • Enroll as an ordering/referring provider.

For information on how to enroll in or opt-out of Medicare, please visit Success.ADA.org/medicare.

Public comments in response to the announcement about the computer matching program can be submitted until Oct. 7 and should be directed to CMS Privacy Officer, Division of Privacy Policy, Privacy Policy and Compliance Group, Office of E-Health Standards & Services, Offices of Enterprise Management, CMS, Room S2-24-25, 7500 Security Boulevard, Baltimore, MD 21244-1850. The program will go into effect no sooner than 40 days after the report of the matching program is sent to Office of Management and Budget and Congress or 30 days after publication in the Federal Register, whichever is later.