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PECOS: A Back Door Way To Force All Physicians To Accept Medicare?

This upcoming January 4, 2010 will prove an important date for any physician who prescribes durable medical equipment for their patients to use in the home.  The Centers for Medicare and Medicaid Services (CMS) have implemented an internet-based enrollment process for Medicare termed PECOS, another progeny of the 1996 HIPAA legislation.  PECOS stands for Provider Enrollment, Chain and Ownership System and was created in large part to prevent fraud.  Yet when I called the PECOS helpline, fraud was not a concern, and it was explained to me that PECOS is an internet version of my Medicare Application.

Since my practice makes house calls, we treat a variety of home-bound patients unable to make it to a doctor’s office without great effort.  We care for stroke patients, quadriplegics, those with end-stage pulmonary disease, and many simply weakened by the effects of advanced age.  Most need equipment like mattresses to prevent recurrent pressure sores, wheelchairs, nebulizer machines, or oxygen.  A patient depends on their physician’s ability to order anything necessary, and it is imperative this be done without creating an exorbitant financial burden or by denying them a Medicare benefit already paid for. But, according to our Home Supplier, if we haven’t enrolled by January 4 then our Medicare & Medicaid patients will have to pay 100% of the cost for any equipment prescribed.

Our practice has opted out of Medicare and left the third-party payer system.  This gives us the freedom and time to make house-calls and fill a growing need in our community.  Yet, lack of freedom is not the main reason so few Medicare doctors make house-calls; Medicare does reimburse for house-calls at a rate similar to office visits, after all.  The third-party payer system forces physicians to create paperwork by moving a relentless herd of patients through their office to make a profit and most can’t afford the 1-2 hours away from their office that house-calls often necessitate.  This explains in large part why we are the only primary care doctors in our area making house calls.

Opting out of Medicare has become increasingly common and is driven by fiscal realities.  The Mayo Clinic, in Scottsdale Arizona, has opted out of Medicare within their Primary Care Department quoting losses of $840 million dollars in 2008 alone. They are now charging any Medicare patients who decide to stay a $250 administration fee including annual costs they estimate at $1,500 a year (3 visits, plus a physical).

Another Arizona Hospital president planning to continue with Medicare stated, “It’s absolutely a fact that Medicare reimbursements in most cases don’t cover the cost of care so we need to identify ways to live in a tighter budget,” stating that this would mean finding a better use of staff and a more efficient delivery of care.  Good luck: that’s been the elusive Holy Grail within Healthcare for decades.

When we were notified that we had to enroll in Medicare and PECOS or the relationships we had forged with many of our patients would be threatened, I began the process of finding out just what was involved in enrolling. Ever the optimist, as I embarked on this endeavor, I hoped, naively, that I would not run into a bureaucratic dead end.

I started by calling the home medical supply company who had notified us of this deadline.  They supplied me with the Health and Human Services (HHS) web address, and then reiterated that if we weren’t participating in PECOS by the deadline they would have no choice but to bill our patients for 100% of all costs incurred for equipment.

Following directions, I took my National Provider Identification (NPI) number to the NPPES (National Plan and Provider Enumeration System) website to create a web account.  I entered my NPI number and was informed that I already had an account (this had been done by a previous employer) and could not access it without the proper username and password. To find out what these were, I called the helpline at 1-800-465-3203 for an NPI specialist.  Fortunately, I was only on hold for 10 minutes before being given my user name and password.

Armed with these, I moved directly to the PECOS website, curious to see if I could enroll online since I am a Medicare Opt-Out physician.  Soon, I read a line stating that PECOS enrollment was for Medicare Part B physicians only, and, not wanting to perjure myself,  I stopped and called the Center for Medicare and Medicaid external users help desk (1-866-484-8049 opt. 2 for PECOS).

I then sat on hold for one hour before giving up, resolving to contact the office first thing the next morning and get into the queue early.  I did just this the next day, and after 90 minutes on-hold, I got through to an office based in San Antonio, Texas.  The rep then told me that his office was “getting slammed on PECOS calls right now” and 50 office workers were responsible for all PECOS-related calls within the entire country.  He apologized for the long wait time, explaining that prior to PECOS, hold times were about five minutes.

His advice was limited technically to how to apply online to PECOS. Too, the rep had no information on Medicare Opt-Out physicians, but thought I could ignore the warning about needing to be a Medicare Part B physician and that I could continue the application process.  However, fearing perjure, I declined and called the Regional Medicare Office.

My journey towards PECOS enrollment has stagnated here, at this regional office.  They’ve told me that, as an Opt-Out physician, it would make no sense for me to apply to PECOS. When I pushed and I asked how I am to prevent my supplier from billing my patients for prescribed equipment, I was told, “I’ll have to get back to you on that one.”  That was a week ago, and my last communication with them was a message informing me that they were still looking into it.

The AMA’s House of Delegates holds a position that no legislation should be made that prevents a patient and physician from privately forming a Patient-Doctor relationship; however, bureaucratic red-tape can be just as effective as any written law thus creating a back-door type of legislation.   With the January 4 deadline looming closer and feeling trapped in a dead end, I ask: what am I, and my patients, to do?



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3 Responses to “PECOS: A Back Door Way To Force All Physicians To Accept Medicare?”

  1. Welcome to the world of Medicare and administrative pricing. Your home visits are of absolutely no value…. to Medicare, despite the fact that they are absolutely invaluable to your home bound patients. There are two predictable consequences of this action by Medicare. First, this will save Medicare money since visits and less likely to happen and you are less likely to prescribe durable equipment for your patients. Second, your patients are screwed. However, it the words of Lilly Tomlin when speaking of the old phone company, “We don’t care because we don’t have to!” Their most measurable and important metric is money saved which trumps your desire to better serve patients. Even if you decided to make some noble statement and continue to make home visits at the same rate it would serve no purpose in the long term except bankrupt your practice and provide a compelling justification not to follow in your footsteps.

  2. Brenda says:

    Wondering if Dr. Steve Simmons ever got a response regarding what to do with PECOS in order to help his cash paying medicare pt’s get their DMEs covered. I am in the same boat. My call to Medicare resulted in being told to put a coverletter prior to the faxed PECOS enrollment form stating that I have opted out of medicare. Of course, makes me extremely nervous and have not taken any further action yet.

  3. Dr. Simmons,
    I can give you a quick glimpse @ the pecos mess from the dme side of things: I am an ocularist, a provider of custom ocular prosthetics, and the vast majority of my referrals come from ophthalmologists & optometrists who have no real concerns, knowledge even, that pecos enrollment need be a concern of their practices; they do not rx home health care, and they view artificial eyes as an infrequent need for their general patients. Oculoplastic surgeons, likewise, refer perhaps a couple of dozen enucleation/eviscerations annually representing just a tiny fraction of their work load.
    I was gladly participating w/ medicare for the past 14 years of my practice, but after notifying my main referal sources of the upcoming pecos problem, only 2 have made the pecos list as of 02/14/10! They seem, truly, not to care/understand/have the time, knowledge, or desire to register beyond their current status.
    Medicare reimbursement represents 45% of our cashflow, and this year we had no choice but change our status to non-par. I cannot imagine asking medicare patients to foot the bill for this medicare allowed item, but it looks like after 4/5/10 that is exactly what we will be required to begin doing. I see this as an attempt not only to combat fraud, but also as an attempt to reduce medicare expenditures by shifting the obligation for a % of otherwise covered items to the patient and/or dme provider.
    I a hoping for another extension and a simplification of enrollment on your end; otherwise, it will be primarily the burden of medicare beneficiaries to “fund” the pecos initiative.
    Good luck, and keep up the good work!
    J. Johnston, C.O.

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