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ADA sees new PECOS enrollment requirement as 'unnecessarily burdensome'

ADA News

July 01, 2010

ADA sees new PECOS enrollment requirement as 'unnecessarily burdensome'

CMS says simplified forms possible; no claims to be rejected 'for the time being'

By Craig Palmer

Washington—Though dentistry has little involvement with Medicare, Medicare may be coming to a dental practice near you, in one way or another, depending.

Q&A

Q. Suppose I refer my patient for a Medicare-covered service and do nothing else?
A. If you do not enroll or opt out, at some point, most likely no later than Jan. 3, 2011, the practitioner who provides the Medicare-covered services to your patient, i.e. the billing provider, will not be able to bill Medicare for the services provided. This doctor may stop accepting patient referrals from you.

Q. What does this mean to me?
A. Of course, if you do nothing there is no consequence to you except that at some point you will no longer be able to refer.

Q. Why PECOS and why now?
A. The rationale is that Medicare wants information on the referring practitioner to reduce fraud and abuse as required by the new health care law. One of their aims is to verify that referring/ordering providers are actually entitled by their education and licensure to perform the referrals.

Q. How do I enroll in Medicare solely for referring and ordering purposes?
A. You may enroll by filling out the paper form CMS-8551 or by using the internet-based PECOS. A covering note saying that you are enrolling only to order and refer must accompany the paper application or the paper Certification Statement generated when you submit a web-based application.

Q. Is it difficult to enroll in PECOS?
A. The enrollment form is complex and must be filled out carefully and accurately. It may be necessary to seek help from a CMS enrollment specialist. An ADA dentist who tried to enroll using the 29-page paper version of the CMS-8551 PECOS needed 15-20 minutes of assistance from a CMS enrollment specialist to work his way through the form because only certain portions of the paper form had to be completed, and without the assistance of the CMS enrollment specialist it was not possible to tell which portions needed to be addressed.

Q. If I enroll electronically just to refer Medicare beneficiaries or order Medicare-covered items or services, can't I just skip the questions that do not apply to me?
A. It is not possible to complete the current electronic application form without entering information applicable only to practitioners who are enrolling in order to receive reimbursements. For example, an applicant must answer the question "Billing agency name and address" before the electronic form will allow movement to the next question.

Q. I am already enrolled in Medicare and eligible to order items or services or refer Medicare beneficiaries.
A. Make sure you have a current enrollment record. CMS says "many" practitioners do not. This is particularly true if you enrolled more than six years ago. You can find out from your designated carrier or by going online and using Internet-based PECOS. A current enrollment record is one that is in the PECOS system and contains the practitioner's National Provider Identifier (NPI). Enrolled practitioners who do not have enrollment records in PECOS and who submit enrollment applications to get their enrollment information into PECOS "should not experience any disruption in Medicare payments as a result of submitting enrollment applications," the agency says.

Q. I am not enrolled in Medicare but I want to refer my patient for a Medicare service.
A. In order to continue to order or refer items or services for Medicare beneficiaries, you must submit an initial enrollment application or opt out of Medicare.

Q. How do I opt-out of Medicare?
A. Go to ada.org to get started. It’s a paper process. The Association has asked CMS to establish a process allowing practitioners to opt out of Medicare by using an electronic format. Practitioners who have opted out of Medicare may order or refer items or services for Medicare beneficiaries. Their opt-out information must be current and must include an affidavit completed every two years. Opt-out doctors whose affidavits are current should have enrollment records in PECOS that contain their NPIs. Bottom line: You have to get into the system to get out of it.

"We are concerned about the unintended consequences of the interim final rule entitled Medicare and Medicaid Programs; Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreements (CMS-6010-IFC) published in the Federal Register on May 5, 2010," the Association told the U.S. Department of Health and Human Services.

In response, HHS Centers for Medicare & Medicaid Services officials told ADA representatives at a July 1 meeting that a simplified process is possible and indicated they were "truly interested in working with us," said an ADA staff member who attended the meeting in Baltimore. The Association will request a carve-out for dentistry when submitting comments on the interim final rule.

CMS officials said they were working on a simplified process, which could delay enforcement of the new PECOS enrollment requirements to 2012, according to ADA representatives at the July 1 meeting.

The IFR would apply to dentists who order or refer items or services for Medicare beneficiaries, even if they do not bill Medicare or provide or supply Medicare-covered items or services. Such ordering or referring dentists will be required to either enroll in PECOS, Medicare’s Provider Enrollment, Chain and Ownership System, or opt out by completing and submitting the necessary forms.

When the IFR takes effect and a practitioner who has neither enrolled or opted out of PECOS orders or refers covered items or services for a Medicare beneficiary, the Medicare claim of the practitioner providing that item or service may be rejected. The rule changes the way Medicare claims will be processed and imposes recordkeeping requirements on practitioners who order or refer items or services.

ADA representatives met July 1 with officials of the Centers for Medicare & Medicaid Services to discuss PECOS and to clarify a June 30 announcement that "CMS will, for the time being, not implement changes that would automatically reject claims based on orders, certifications, and referrals made by providers that have not yet had their applications approved by July 6, 2010."

The new regulatory requirement is described in a Medicare Learning Network article posted at www.cms.gov/MLNMattersArticles/
downloads/SE1011.pdf:

"Orders or referrals by dentists. Most dental services are not covered by Medicare; therefore, most dentists do not enroll in Medicare. Dentists are a specialty that is eligible to order and refer items or services for Medicare beneficiaries (e.g. to send specimens to a laboratory for testing). To do so, they must be enrolled in Medicare. They may enroll by filling out the paper CMS-8551 or they may use Internet-based PECOS. They must include a covering note with the paper application or with the paper Certification Statement that is generated when submitting a web-based application that states that they are enrolling in Medicare only to order and refer. They will not be submitting claims to Medicare for services they furnish to Medicare beneficiaries."

Or a referring/ordering dentist could opt out of Medicare, a whole 'nother matter requiring a definite action on the dentist's part.

So who is a referring or ordering dentist in this regulatory context? ADA's Council on Government Affairs says this is a dentist who refers a patient to another practitioner for a Medicare-covered service or who orders a Medicare-covered item. "This new requirement does NOT require you to enroll as a provider who is eligible to receive reimbursement from Medicare. But it does require you either to enroll as a referring-only provider or opt out by completing the required paperwork."

The Council at its May meeting recommended the Association seek a legislative remedy while acting to help dentists comply by developing tools to help dentists complete the Medicare enrollment form and reissuing Medicare opt-out material developed in a 2002 joint effort by the Association and the HHS Centers for Medicare & Medicaid Services.

Glossary

CMS—Centers for Medicare & Medicaid Services, the Department of Health and Human Services agency that administers public health care coverage www.cms.gov.

HHS—Parent agency www.hhs.gov for CMS and other public health and human services activities including multi-faceted dental programs.

IFR—Interim final rule with comment period published in the May 5, 2010 Federal Register http://edocket.access.gpo.gov/2010/2010-10505.htm to make PECOS effective July 6, 2010 as required by The Patient Protection and Affordable Care Act, Public Law 111-148.

MLN—Medicare Learning Network, an online CMS information site for Medicare fee-for-service health care professionals www.cms.gov/MLNMattersArticles/.

NPI—National Provider Identifier, a unique 10-digit identification number for covered health care providers www.cms.gov/NationalProvIdentStand/.

PECOS—Medicare's Internet-based Provider Enrollment, Chain and Ownership System http://www.cms.gov/MedicareProviderSupEnroll/
04_InternetbasedPECOS.asp, which is managed by CMS.

The ADA believes as many as 180,000 dentists may be affected by the requirement to enroll or opt out and estimates that 3 to 4 percent of practicing dentists are enrolled in PECOS or have opted out. The numbers aside, dental patients are aging along with the rest of us and many more are moving to Medicare, which, as noted, does not cover most dental services, one exception being medically necessary services provided in a hospital, often by oral surgeons. And some non-elderly patients may be Medicare beneficiaries.

The new PECOS requirement was scheduled to take effect Jan. 3, 2011, by HHS regulation, but Congress told HHS to start the system by July 6, 2010. The IFR does just that, citing an implementation date of July 6, 2010, for the requirement in the Patient Protection and Affordable Care Act (Public Law 111-148) that providers who refer Medicare beneficiaries for services or order items covered by Medicare must be enrolled in PECOS or opt-out of Medicare.

As Association officials pointed out in a letter to HHS Secretary Kathleen Sebelius, there is "a great deal of confusion" about that date and what it means. The Association asked for clarification.

"The ADA is concerned that without timely adjustments in the enrollment and opt-out procedures, the IFR requirements will be unnecessarily burdensome on dentists and other referring/ordering-only providers, as well as CMS," said the letter signed by ADA President Ron Tankersley and Executive Director Kathleen O'Loughlin. "A processing bottleneck is inevitable."

The Association recommends that the HHS Centers for Medicare & Medicaid Services:

develop a simplified enrollment form specifically for ordering/referring providers who do not submit Medicare claims;
establish an electronic opt-out process;
identify an effective date and,
postpone enforcement until January 2011 to give stakeholders time to understand and comply with the new requirements.

"The ADA is more than willing to work with CMS to provide assistance to dentists in the enrollment process similar to the joint effort between CMS and ADA in 2002 to publicize the opt-out provisions," Association officials told HHS Secretary Sebelius and officials of the Centers for Medicare & Medicaid Services.

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