Medicare will deny ordered/ referred claims without enrollment
As of Jan. 6, Medicare will deny claims for services ordered or referred by a physician who is not enrolled in Medicare. The requirement was included in the Affordable Care Act to address multiple issues, including combating fraud and abuse by making sure only those physicians who are appropriately en- rolled in Medicare are providing services to Medicare beneficia- ries; ensuring that nonphysician providers are not ordering and referring services they are not allowed to under the Medicare rules; and making sure that physicians maintain updated enroll- ment records with Medicare. Here are some steps you can take to make sure your claims
aren’t denied:
• Verify enrollment. To avoid denied claims for you and for those to whom you refer, use TMA’s free PECOS lookup tool,
www.texmed.org/pecos, to make sure you and physicians from whom you receive orders/referrals have an enrollment record in the Centers for Medicare & Medicaid Services (CMS) Provider Enrollment, Chain and Ownership System (PECOS). You also can check the Medicare Ordering and Referring File at
www.texmed.org/OrderAndReferral. (TMA’s tool is based on the CMS data file.) Or, contact Novitas at (877) 252-8782 (choose option 4), and ask if you have an enrollment record in PECOS.
• Enroll in PECOS, if necessary. If you order and refer, and you do not have a record in PECOS, you need to submit either an electronic application through PECOS or a paper enrollment to Medicare. More information on enrollment guidelines is available on the TMA website above.
• Submit claims properly. TMA staff also recommend that physicians monitor claims closely for any rejections indicat- ing the ordering/referring physician is not enrolled, and, if necessary, contact the physician and ask that he or she enroll in Medicare to prevent future denials.
der and refer services or receive those orders and referrals. Mr. Vaughan said, “Novitas does not believe that any potential delays in pro- vider enrollment will affect a provider’s ability to order/refer services.” He says the majority of new applica-
tions processed, including those solely for ordering/referring, are “consistent” with its contract requirements. He add- ed that Medicare processing timeframes vary by application type and whether ad- ditional information is required, which CMS also reiterated. Roughly half of the enrollment applications Novitas gets from physicians are incomplete, which causes processing delays. For example, Novitas told TMA that in June 2013, it received more than 150,000 claims with an incomplete, missing, or invalid order- ing provider name or national provider identifier (NPI). Novitas processes 80 percent of ordering/referring applica- tions within 60 calendar days, in line with CMS requirements. “The amount of providers who remain
unenrolled in PECOS is limited, and No- vitas is prepared to expedite processing of [ordering/referring] applications to mitigate interruption in claim payment,” Mr. Vaughan said.
Audit pressure
TMA also is tracking concerns from phy- sicians over heavy prepayment audits, particularly when it comes to high-level evaluation and management (E&M) procedures. TMA is aware that CMS has stepped up scrutiny of certain services. But Ms. Davis says that should not trans- late to across-the-board audits. Ahmed Mattar, MD, says his experi- ence demonstrates otherwise. Ongoing audits by Novitas pushed
the Wichita Falls family physician to the brink of shutting down Wichita Falls Family Health Center last spring. For the past year, the carrier has routinely asked the clinic to produce as many as 50 to 60 charts at a time before paying claims. His staff estimate that six out of every 10 charts are subjected to review. The heavy audits translated to pay- ment delays that forced the clinic to take out a loan to keep its doors open. Some staff were let go, and physicians fore-
30 TEXAS MEDICINE March 2014
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