CMS Ordering/Referring Policy
delayed until April 5
The Centers for Medicare and Medicaid Services (CMS) has delayed until
April 5, 2010, a policy
of non-payment for services ordered or referred by physicians not enrolled
in the Medicare program, as a result of efforts by the ACC and other provider
organizations. Under this policy, practitioners who furnish services to
patients referred by other providers who are not registered in the Medicare
provider enrollment system (PECOS) or who are not in the contractor’s
master file by Jan. 1, 2010, would not have been paid for those services.
This meant that if the practitioner furnishing the service was enrolled
but the ordering or referring practitioner was not, CMS would not make
payment for the service. However, as a result of efforts by the ACC and
other provider organizations, CMS has agreed to delay implementation of
this new policy until April 5.
A number of problems were found with the policy. Many providers learned
of the policy change through a new remark code on providers’ Explanation
of Benefits (EOB) in October. However, as providers began questioning
the new remark code, CMS discovered that the edit also went to providers
who enrolled in PECOS between November 2003 and May 2006 because their
National Provider Identifiers (NPI) had not been added to PECOS. This
resulted in a larger number of providers receiving the remark code on
their EOBs than actually will be affected by this change in policy.
The agency is in the process of loading into the enrollment system the
NPIs of all practitioners who enrolled as Medicare providers. According
to CMS officials, this should take 6 to 8 weeks and should alleviate the
problem for a large number of practitioners.
CMS has worked with its contractors to create a file
listing all of the practitioners eligible to order and/or refer for
Medicare services. This file contains all of the NPIs and legal business
names of eligible professionals. Practitioners should use this list to
determine if they need to revalidate their enrollment information immediately
or should wait until prompted by their Medicare contractor to do so. This
list can also be used by practices receiving orders and/or referrals to
determine if they will be paid for services furnished by their referral
sources.
The ACC opposed the changes to the ordering/referring policy and recently
sent a joint
letter to CMS citing the numerous problems in the implementation of
the policy, both legal and practical. The ACC will continue to monitor
CMS’ activities with respect to this new policy to ensure minimal
effects on practitioners who receive referrals.
|
