RE: Problem With SCAN Newport IPA or Monarch and Father-In-Law

[Guest guest]

Calafornia IMPs can you explain how to negotiate SCAN medicare HMO. My father-in-law is 79 and has dementia, BPH, and prostate cancer. He was a Long Beach GP from 1959 till 2005. He really needs a local doctor to treat him the way he has been treated, but he has been run in circles without helping him with post void dribbling. Primary MDs have granted referrals to subspecialists but referrals denied. He lives in Newport Beach and comes with a wife who is 74 and has been a nurse since 1957. They need good IMPing care to improve the quality of the remainder of their lives. Scan has prevented them from transfering back to regular medicare since March, 2009.

Any suggestions would be appreciated. No one wants to see him until he seperates from the HMO and IPA's

To: ; Practice Management Issues Sent: Wed, December 30, 2009 1:20:06 PMSubject: Provider Enrollment, Chain and Ownership System (PECOS) --> Re: Medicare's PECOS database [1 Attachment]

I'm still not sure I understand this.

Although, when I go to...

https://pecos. cms.hhs.gov/ pecos/login. do

And log in using my NPI login I set up in the past --- same login used at...

https://nppes. cms.hhs.gov/ NPPES/Welcome. do

....I am in the system -- so apparently updated and OK.

But it's still confusing. Also, it sounds like the problems will come down more on the Durable Medical Equipment DME suppliers (who will have their claims rejected if the ordering provider isn't in the PECOS) than on providers specifically.

This is probably the best explanation of why you (as medicare provider) would want to make sure you are in PECOS -- basically, if you order a lot of DME -- your suppliers (wheelchairs, oxygen supplies, etc) will have their claims rejected and have to get you to update your information in PECOS before they can get paid.

At least that is my take on everything.

============ ========= ===

http://www.oandp. com/articles/ 2009-12_01. asp

According to the policy, in order for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claims to be paid, the physician or non-physician referrer/prescriber (described as the "ordering/referring provider") must be enrolled in Medicare and registered on the database of a program titled the Medicare Provider Enrollment, Chain, and Ownership System (PECOS). The ordering/referring providers must be listed in the PECOS database with their individual National Provider Identifier (NPI) number and must have enrolled or updated their entry in the database since November 2003. Ordering/referring providers who were previously not enrolled in Medicare, including those whose services are not covered by Medicare, such as Department of Veterans Affairs (VA) and Public Health Service physicians, are included in the mandate, and if they do not enroll in Medicare and join the PECOS database, they will no longer be able to refer their patients

for DMEPOS through Medicare.

Physician Complications

Stark, DMEPOS consultant and reimbursement specialist at MiraVista LLC, wrote in a statement to her customers, "At this point, many referral sources have obtained an NPI [through the NPPES system], but they may or may not have registered with the PECOS system. To make matters worse, many physicians remain unaware of the recent requirement to enroll in PECOS, as their claims are not likely to be affected by these new DME-specific edits. This enrollment process appears to go more quickly for individual practitioners but can be a lengthy process taking up to 60 days for organizational/ group practices."

============ ========= ========= ==

BTW, horse's/medicare's mouth is below and attached...

http://www.cms. hhs.gov/MLNMatte rsArticles/ downloads/ MM6421.pdf

• During Phase 1 (October 5, 2009-April 4, 2010): If the ordering/referring provider is on the claim, Medicare will verify that the ordering/referring provider is in PECOS and is eligible to order/refer in Medicare. If the ordering/referring provider is not in PECOS or is in PECOS but is not of the type/specialty to order or refer, the claim will continue to process.

1. If the DMEPOS supplier claim is an ANSI X12N 837P standard electronic claim, the DMEPOS supplier will receive a warning message on the Common Electronic Data Interchange (CEDI) GenResponse Report.

2. If the DMEPOS supplier claim is a paper CMS-1500 claim, the DMEPOS supplier will not receive a warning and will not know that the claim did not pass these edits.

•During Phase 2, (April 5, 2010 and thereafter): If the ordering/referring provider is not on the claim, the claim will not be paid. If the ordering/referring provider is on the claim, Medicare will verify that the ordering/referring provider is in PECOS and eligible to order and refer. If the ordering/referring provider is not in PECOS or is in PECOS but is not of the specialty to order or refer, the claim will not be paid. It will be rejected.

1. If the DMEPOS supplier claim is an ANSI X12N 837P standard electronic claim, the DMEPOS supplier will receive a rejection message on the CEDI GenResponse Report.

2. If the DMEPOS supplier claim is a paper CMS-1500 claim, the DMEPOS supplier will see the rejection indicated on the Remittance Advice.

• In both phases, Medicare will verify the NPI and the name of the ordering/referring provider reported on the ANSI X12N 837P standard electronic claim against PECOS.

• When furnishing names on the paper claims, be sure not to use periods or commas within the name. Hyphenated names are permissible.

• Providers who order or refer may want to verify their enrollment in PECOS. They may do so by accessing Internet-based PECOS at https://pecos. cms.hhs.gov/ pecos/login. do on the CMS website. Before using

Internet-based PECOS, providers should read the educational material about Internet-based PECOS that is available at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l/04_Internetbas edPECOS.asp on the CMS website. Once at that site, scroll to the downloads section of that page and click on the materials that apply to you and your practice.

============ ========= ========= ==

http://homecaremag. com/news/ pecos-medicare- 20091023/

snip/snip

Late last year, CMS rolled out its Internet-based PECOS, which allows physicians and other practitioners to enroll in Medicare, check on the status of an application or make a change in their enrollment information. But according to officials on the call, even if physicians are enrolled in Medicare but have not submitted any updates or changes to their enrollment record since 2003, it's likely their information won't be in the new system.

The January deadline concerns physician and non-physician practitioners who must be enrolled in PECOS. As of Oct. 5, if the ordering/referring physician on a claim is not in the system, or is in PECOS but not of the type/specialty to order or refer, the claim will continue to process — and the provider will receive a warning message from the Common Electronic Data Interchange (CEDI). Beginning Jan. 1, such claims will reject.

snip/snip

Physicians have 'no idea' what we're talking about

Question: I would just ask that continuing education go on with the physicians, because we have had the same thing that [Rose Schafhauser] mentioned when she called earlier. We are calling our physicians, and they have no idea what we are talking about.

Bossenmeyer: The question should be to the physician, 'Have you updated your enrollment information with Medicare since November 2003?' If they are a long-standing Medicare physician and have not made any changes in their enrollment information, they likely have not updated their information.

Question: The answer we are getting to that is 'Why is it any of your business? Why are you as a DME supplier telling us what to do?'

Bossenmeyer: Medicare will be raising this issue at the next physician Open Door Forum, and we will continue to educate physicians via conference calls and with our contractors to update and maintain their enrollment in the Medicare program.

Why should the burden fall on DME providers?

Question: Regarding the PECOS system, will the physician's claim also be rejected in January 2010 if they are not in the system?

Bossenmeyer: Physicians' claims will continue to be processed.

Question: Why are DME claims then being rejected?

Bossenmeyer: Medicare requires that we know who the physician is, that the physician is licensed and that they are qualified to continue to participate in the Medicare program. To implement that provision, physicians must be enrolled in Medicare with a current enrollment record within Medicare.

Question: So that burden falls on [DME providers] to make sure?

Bossenmeyer: Medicare will continue to conduct outreach to physicians. Again, there are only a limited number of nonphysician practitioners who are eligible, and those are physician assistants, certified clinical nurse specialists, nurse practitioners, clinical psychologists, certified nurse midwives and clinical social workers. So if you are receiving orders and referrals from nonphysician practitioners other than those, those will not be eligible for future payment beginning in January of next year.

How come physicians don't know they should register in PECOS?

Question: How have physicians been notified that they have to register with PECOS?

Bossenmeyer: CMS has encouraged physicians since November of 2006 to update their enrollment info with Medicare. We are doing revalidations where we are requiring physicians and other practitioners to update their Medicare enrollment information. If they do not respond to the revalidation, then Medicare would take some action to revoke their billing privileges.

Prior to the Q & A session, Bossenmeyer reminded providers that CR 6421 also requires that claims coming from DMEPOS suppliers must include the legal business name of the physician.

On the competitive bidding front, CMS' Kaiser, deputy director of DMEPOS policy, added that the bidding window for the Round 1 rebid closes on Dec. 21, and that Nov. 21 is the "covered document review date," which is designed to motivate providers to turn in all financial documents no later than that date. If providers make the deadline, they will be notified of any missing documents. However, they will not be told if those documents are correct and/or filled out properly.

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http://www.aanp. org/AANPCMS2/ LegislationPract ice/Regulation/ Medicare+ Provider+ Enrollment+ Chain+and+ Ownership+ System+PECOS+ Delay+in+ Implementing. htm

Although enrolled in Medicare, many physicians and non-physician practitioners who are eligible to order items or services or refer Medicare beneficiaries to other Medicare providers or suppliers for services do not have current enrollment records in Medicare. A current enrollment record is one that is in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and also contains the physician/non- physician practitioner’ s National Provider Identifier (NPI). Under Phase 2 of the above referenced CRs, a physician or non-physician practitioner who orders or refers and who does not have a current enrollment record that contains the NPI will cause the claim submitted by the Part B provider/supplier who furnished the ordered or referred item or service to be rejected.

CMS continues to urge physicians and non-physician practitioners who are enrolled in Medicare but who have not updated their Medicare enrollment record since November 2003 to update their enrollment record now. If these physicians and non-physician practitioners have no changes to their enrollment data, they need to submit an initial enrollment application which will establish a current enrollment record in PECOS.

For physicians and non-physician practitioners who order or refer—

• If you are not enrolled in the Medicare program, or if you enrolled more than 6 years ago and have not submitted any updates or changes to your enrollment information in more than 6 years, you do not have an enrollment record in PECOS. In order to continue to order or refer items or services for Medicare beneficiaries, you will have to submit an initial enrollment application. You may do so either by (1) using Internet-based PECOS (which transmits your enrollment application to the Medicare carrier or A/B MAC via the Internet—be sure to mail the signed and dated Certification Statement to the carrier or A/B MAC immediately after submitting the application) , or (2) filling out the appropriate paper Medicare provider enrollment application( s) (CMS-855I and CMS-855R, if appropriate) and mailing the application,

along with any required additional supplemental documentation, to the local Medicare carrier or A/B MAC, who will enter your information into PECOS and process your enrollment application. Information on how to enroll in Medicare is found on the Medicare provider/supplier enrollment web site at www.cms.hhs. gov/MedicareProv iderSupEnroll.

• If you are already enrolled in Medicare, make sure you have a current enrollment record. You can find out if you have an enrollment record in PECOS by calling your designated carrier or A/B MAC or by going on-line, using Internet-based PECOS, to view your enrollment record. We will be posting information to the Medicare provider/supplier enrollment web site that will guide you through this process. Information about Internet-based PECOS and a link to Internet-based PECOS can be found on the Medicare provider/supplier enrollment web site. Before using Internet-based PECOS, we recommend that you read the information that is posted there and that is available in the downloadable documents section.

• If you are a dentist or a physician with a specialty such as a pediatrics who is eligible to order or refer items or services for Medicare beneficiaries but have not enrolled in Medicare because the services you provide are not covered by Medicare or you treat few Medicare beneficiaries, you need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries.

• If you are a physician who is employed by the Department of Veterans Affairs, the Public Health Service, or the Department of Defense Tricare program but have not enrolled in Medicare because you would not be paid by Medicare for your services, you need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries.

If you are a resident who has a medical license but have not enrolled in Medicare because you would not be paid by Medicare for your services, you do not need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries. The teaching physician—not the resident—should be identified in claims as the ordering/referring provider when a resident orders or refers items or services for Medicare beneficiaries.

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http://www.lamedica re.com/provider/ viewarticle. aspx?articleid= 7578

Guidance on Using Internet-based Provider Enrollment, Chain and Ownership System (PECOS)Reference: SE0914Published Online: 8/5/2009

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Provider Types AffectedThis article is for physicians, non-physician practitioners, and organization providers and suppliers who are enrolled or wish to enroll in the Medicare program. NOTE: Suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) do not, at this time, have the option of using Internet-based PECOS. The availability of Internet-based PECOS to DMEPOS suppliers will be announced at a future date.

Provider Action NeededThis Special Edition (SE) 0914 article alerts physicians, non-physician practitioners, providers and suppliers that the Centers for Medicare & Medicaid Services (CMS) is reaching out to assist those providers and suppliers who wish to use Internet-based PECOS for enrollment in Medicare and/or to maintain the currency of the enrollment data they have on file with Medicare. Internet-based PECOS offers physicians, non-physician practitioners, and organization providers and suppliers a means of applying for enrollment and updating their enrollment information faster than the paper enrollment process that required the use of the paper CMS-855 series of forms. The documents that describe Internet-based PECOS are available at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l/04_Internetbas

edPECOS.asp# TopOfPage on the CMS website. BackgroundInternet-based PECOS has been available to physicians and non-physician practitioners since December 2008, and to organization providers and suppliers since April 1, 2009. (As noted above, DMEPOS suppliers may not use the system at this time, but will be able to do so at a future date.) There are certain pre-requisites that must be met before one can use Internet-based PECOS. In addition, the processes for physicians and non-physician practitioners differ somewhat from those used by provider and supplier organizations. This article will present a high-level overview of these processes and will direct physicians, non-physician practitioners, providers, and organization providers and suppliers to other sources available via the Medicare Learning Network (MLN) that will enable them to learn more. An important benefit for all physicians, non-physician practitioners, and organization providers and suppliers is that Internet-based PECOS speeds up the completion of their initial Medicare enrollment application as well as the update of their enrollment information when changes occur. CMS timelines for Medicare contractors to process Internet-submitted enrollment applications are more stringent than those for paper:

Contractors must process 90 percent of web-based applications (e.g., initial enrollments and changes of information) within 45 days of receipt of the signed and dated Certification Statement and supporting documentation. Contractors must process 80 percent of initial paper applications within 60 days, and 80 percent of paper changes of information within 45 days.

With the temporary exception of the DMEPOS suppliers, physicians, non-physician practitioners, and organization providers and suppliers can use the Internet to enroll in Medicare, to update their existing enrollment information, to view their existing enrollment information, or to voluntarily terminate their Medicare enrollment. Once a provider or supplier submits an application via the web, the provider or supplier can view the status of that application beginning 15 days after the submission. (The 15-day time frame allows sufficient time for the Medicare enrollment contractor to have received the signed and dated Certification Statement and begin action on the application. More information about the Certification Statement will be supplied later in this article.)

One crucial point that physicians, non-physician practitioners, and organization providers and suppliers should understand is that, if they want to use Internet-based PECOS to update or view their Medicare enrollment information, or to terminate their enrollment in Medicare, they must first have an enrollment record in PECOS. If a physician, non-physician practitioner, or organization provider or supplier enrolled in Medicare more than 5 years ago and has not submitted any updates or changes to their enrollment record over the past 5 years, it is very likely that the provider or supplier is not in PECOS. If one of these providers or suppliers accesses Internet-based PECOS attempts to view or update the enrollment record, there will be nothing there to view or update. Providers and suppliers who find themselves in this situation will have to revalidate their enrollment with Medicare. In order to revalidate, the provider or supplier has to furnish all

the information necessary to initially enroll in Medicare. This will get the provider or supplier into PECOS and will ensure that their enrollment information, which may have changed over the years, is current. If they never submitted the CMS-588 Electronic Funds Transfer Agreement, they will have to do so as part of the revalidation. Providers and suppliers can revalidate their enrollment via Internet-based PECOS or they can fill out the appropriate paper CMS-855 Medicare provider enrollment forms and mail them to the appropriate enrollment contractor.

The remainder of this article provides the overviews of the processes for using Internet-based PECOS and identifies other sources of information.

Physicians and Non-Physician PractitionersBefore a physician or non-physician practitioner initiates a Medicare enrollment action using Internet-based PECOS, he or she will need the following: An active National Provider Identifier (NPI); A National Plan and Provider Enumeration System (NPPES) User ID and password; Personal identifying information, which includes the physician’s or non-physician practitioner’ s legal name on file with the Social Security Administration, date of birth, and Social Security Number; Professional license and certification information, which includes information regarding the physician’s or non-physician practitioner’ s professional license, professional school degrees or certificates; Practice location information, which includes information regarding the physician’s or non-physician practitioner’ s medical practice location; The legal business name of a solely-owned Professional Association (PA), Professional Corporation (PC), or Limited Liability Company (LLC) on file with the Internal Revenue Service and appearing on the IRS CP575 form; A photocopy of the CP-575 form; The NPI of the PA, PC, or

LLC; and Any Federal, State, and/or local (city/county) business licenses, certifications and/or registrations specifically required by that business to operate as a health care facility; and If applicable, information about any final adverse action that impacts the physician or non-physician practitioner.

Internet based PECOS can be accessed with the same User ID and password that a physician or non-physician practitioner uses for NPPES. If the physician or non-physician practitioner does not have an NPPES User ID and password and needs help in obtaining one, he or she may contact the NPI Enumerator at 1- or send an email to customerservice@ npienumerator. com on the Internet.

Note:CMS recommends that a physician or non-physician practitioner change his/her NPPES password before accessing Internet based PECOS for the first time and at least once a year thereafter. Although the User ID cannot be changed, the password should be changed periodically – at least once a year. If you need help in changing your password, contact the NPI Enumerator at 1- or send an email to customerservice@ npienumerator. com on the Internet. For physicians and non-physician practitioners, there are three basic steps to completing an enrollment action using Internet-based PECOS. Use your National Plan and Provider Enumeration System (NPPES) User ID and password to log on to Internet-based PECOS at https://pecos. cms.hhs.gov/ pecos/login. do ; Complete, review, and submit the electronic enrollment application via Internet-based PECOS; Print, sign and date the Certification Statement and mail the Certification Statement and all supporting paper documentation to the designated Medicare contractor within 7 days of electronic submission.

Note:A Medicare contractor will not process an Internet enrollment application without receipt of the signed and dated Certification Statement. In addition, the effective date of filing an enrollment application is the date the Medicare contractor receives the signed Certification Statement that is associated with the Internet-submitted application. The Certification Statement must be signed by the physician or non-physician practitioner enrolling or making changes to enrollment information. Signatures must be original and in ink (blue ink recommended) . Copied or stamped signatures or dates will not be accepted.

The physician or non-physician practitioner assumes full and complete liability for new and updated Medicare enrollment information that is transmitted to the enrollment contractor via Internet-based PECOS once the enrollment contractor receives the signed and dated Certification Statement.

While CMS encourages physicians and non-physician practitioners to print and retain a copy of the Internet-submitted enrollment application for their records, physicians and non-physician practitioners should only mail the Certification Statement and supporting documentation to the designated Medicare contractor. Do not mail the copy of the enrollment application to the designated Medicare contractor; to do so may delay the processing of the application.

For more information about Internet-based PECOS, along with questions and answers (Q & As), go to the Downloads section at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l/04_Internetbas edPECOS.asp# TopOfPage on the CMS website.

Provider and Supplier OrganizationsBefore a provider or supplier organization can use Internet based PECOS, the organization’ s Authorized Official must take the first step. Below is the process that occurs for an organization provider or supplier to gain access to Internet-based PECOS:

The organization provider/supplier’ s Authorized Official (AO) goes into PECOS I & A and registers. As part of this process, the AO must mail a photocopy of the CP-575 to the CMS EUS Help Desk so that the Help Desk can verify the organization provider/supplier. The Help Desk verifies both the organization provider/supplier and the AO, and approves the AO’s registration. The AO receives a system-generated e-mail indicating that the registration has been approved. Once the AO receives this notification, the AO can let the end-user know that he/she can register in PECOS. The end-user goes into PECOS I & A and registers. The registration request will be directed to the AO of the provider/supplier organization. The AO must approve or reject the end-user in PECOS I & A. Once the end-user has been approved in PECOS I & A by the AO for access on behalf of the organization provider/supplier, the end-user will receive a system-generated e-mail indicating that he/she has been approved. The end-user then logs into PECOS and downloads the Security Consent Form. He or she fills it out, obtains the signature/date of signature of the AO, and mails the completed Security Consent Form to the CMS EUS Help Desk at P.O. Box 792750, San , TX 78216. The Help Desk verifies the information on the Security Consent Form and also calls the AO to verify that the AO did, in fact, sign the Security Consent Form. Once the information on the security Consent Form has been confirmed, the Help Desk approves the Security Consent Form in PECOS and an e-mail is sent to the AO notifying the AO that the end user’s organization has been approved to use Internet-based PECOS on behalf of the organization provider/supplier. It is the AO’s responsibility to notify the end-user’s organization that the end-user can now use Internet-based PECOS. An e-mail is sent to the AO (step 9) because the AO is ultimately responsible for the enrollment information and who has access to that enrollment information. It is the AO’s responsibility to inform the end-user that the Security Consent Form has been approved.

Note:The Security Consent Form is completed only one time to establish the relationship between the provider or supplier organization and the employer organization whose employee(s) would submit enrollment applications on behalf of the provider or supplier organization. More than one individual may request access to Internet-based PECOS for a given provider or supplier organization, but the Security Consent Form is generated and completed by the first (if more than one) approved user who logs on to Internet-based PECOS to submit an enrollment application for the given provider or supplier organization. A Security Consent Form must be completed, signed and dated, and mailed to the CMS EUS Help Desk even if the employer organization is the provider or supplier organization. More detail about obtaining access to Internet-based PECOS for providers and suppliers can be found in the document entitled, "Getting Started with Internet-based Provider Enrollment, Chain and Ownership System (PECOS) – Information for Provider and Supplier Organizations," along with Q & As is available at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l/Downloads/ OrganizationGett ingStarted. pdf on the CMS web site.

Limitations of Internet-based PECOS for Provider and Supplier OrganizationsThere are some scenarios that Internet-based PECOS cannot accommodate at this time; they will be available at a future date. These scenarios are: Changes in Taxpayer Identification Number (TIN). These must be done using the paper enrollment application (CMS-855). Changes in Legal Business Name (LBN). These must be done using the paper enrollment application (CMS-855). An enrolled Medicare Part A provider or supplier organization wants to enroll with a Medicare carrier or A/B Medicare Administrative Contractor (MAC) to bill for Part B services. This must be done using the paper enrollment application (CMS-855).

These scenarios are listed in the document entitled, "Overview of Internet-based Provider Enrollment, Chain and Ownership System (PECOS) – Information for Provider and Supplier Organizations," available at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l/Downloads/ OrganizationOver view.pdf on the CMS website.

Additional InformationThe CMS External User Services (EUS) Help Desk contact information for providers and suppliers using Internet-based PECOS can be found at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l/Downloads/ ContactInformati on.pdf on the CMS website. The Help Desk hours of operation are Monday – Friday, from 6 a.m. to 6 p.m. Central Standard Time. The Help Desk toll-free number is 1- and their e-mail address is eussupportcgi (DOT) com. Questions about accessing and using Internet-based PECOS should be directed to the CMS EUS Help Desk. The overall CMS site regarding provider and supplier enrollment can be found at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l on the CMS website. From there, click on "Internet-based PECOS" on the left-hand side to go to information specific to Internet-based PECOS.

[Guest guest]

,

Sounds like he has to stay with Scan?  Greater Newport Physicians, an IPA that is the only decent one I know around here, takes Scan, but their website says currently closed to new for Scan.  https://www.accessgnp.com/gnpweb/  They do take the other senior plans.  They actually somehow seem to be able to provide decent care (not always great) under the HMO's when no one else here can.  Newport Family Medicine has good docs (Kathleen Laughlin, but others also) if he can use them.

Sharon

Sharon McCoy MDRenaissance Family Medicine10 McClintock Court; Irvine, CA  92617PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax:  www.SharonMD.com

 

Calafornia IMPs can you explain how to negotiate SCAN medicare HMO. My father-in-law is 79 and has dementia, BPH, and prostate cancer.  He was a Long Beach GP from 1959 till 2005.  He really needs a local doctor to treat him the way he has been treated, but he has been run in circles without helping him with post void dribbling.  Primary MDs have granted referrals to subspecialists but referrals denied. He lives in Newport Beach and comes with a wife who is 74 and  has been a nurse  since 1957.  They need good IMPing care to improve the quality of the remainder of their lives.  Scan has prevented them from transfering back to regular medicare since March, 2009.

 

Any suggestions would be appreciated.  No one wants to see him until he seperates from the HMO and IPA's

 

 

To: ; Practice Management Issues

Sent: Wed, December 30, 2009 1:20:06 PMSubject: Provider Enrollment, Chain and Ownership System (PECOS) --> Re: Medicare's PECOS database [1 Attachment]

 

I'm still not sure I understand this.

Although, when I go to...

    

     https://pecos. cms.hhs.gov/ pecos/login. do

 

And log in using my NPI login I set up in the past --- same login used at...

 

     https://nppes. cms.hhs.gov/ NPPES/Welcome. do

 

....I am in the system -- so apparently updated and OK.

 

But it's still confusing. Also, it sounds like the problems will come down more on the Durable Medical Equipment DME suppliers (who will have their claims rejected if the ordering provider isn't in the PECOS) than on providers specifically.

 

This is probably the best explanation of why you (as medicare provider) would want to make sure you are in PECOS -- basically, if you order a lot of DME -- your suppliers (wheelchairs, oxygen supplies, etc) will have their claims rejected and have to get you to update your information in PECOS before they can get paid.

 

At least that is my take on everything.

 

============ ========= ===

http://www.oandp. com/articles/ 2009-12_01. asp

 

According to the policy, in order for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claims to be paid, the physician or non-physician referrer/prescriber (described as the " ordering/referring provider " ) must be enrolled in Medicare and registered on the database of a program titled the Medicare Provider Enrollment, Chain, and Ownership System (PECOS). The ordering/referring providers must be listed in the PECOS database with their individual National Provider Identifier (NPI) number and must have enrolled or updated their entry in the database since November 2003. Ordering/referring providers who were previously not enrolled in Medicare, including those whose services are not covered by Medicare, such as Department of Veterans Affairs (VA) and Public Health Service physicians, are included in the mandate, and if they do not enroll in Medicare and join the PECOS database, they will no longer be able to refer their patients for DMEPOS through Medicare.

 

Physician Complications

Stark, DMEPOS consultant and reimbursement specialist at MiraVista LLC, wrote in a statement to her customers, " At this point, many referral sources have obtained an NPI [through the NPPES system], but they may or may not have registered with the PECOS system. To make matters worse, many physicians remain unaware of the recent requirement to enroll in PECOS, as their claims are not likely to be affected by these new DME-specific edits. This enrollment process appears to go more quickly for individual practitioners but can be a lengthy process taking up to 60 days for organizational/ group practices. "

============ ========= ========= ==

BTW, horse's/medicare's mouth is below and attached...

http://www.cms. hhs.gov/MLNMatte rsArticles/ downloads/ MM6421.pdf

• During Phase 1 (October 5, 2009-April 4, 2010): If the ordering/referring provider is on the claim, Medicare will verify that the ordering/referring provider is in PECOS and is eligible to order/refer in Medicare. If the ordering/referring provider is not in PECOS or is in PECOS but is not of the type/specialty to order or refer, the claim will continue to process.

1. If the DMEPOS supplier claim is an ANSI X12N 837P standard electronic claim, the DMEPOS supplier will receive a warning message on the Common Electronic Data Interchange (CEDI) GenResponse Report.

2. If the DMEPOS supplier claim is a paper CMS-1500 claim, the DMEPOS supplier will not receive a warning and will not know that the claim did not pass these edits.

•During Phase 2, (April 5, 2010 and thereafter): If the ordering/referring provider is not on the claim, the claim will not be paid. If the ordering/referring provider is on the claim, Medicare will verify that the ordering/referring provider is in PECOS and eligible to order and refer. If the ordering/referring provider is not in PECOS or is in PECOS but is not of the specialty to order or refer, the claim will not be paid. It will be rejected.

1. If the DMEPOS supplier claim is an ANSI X12N 837P standard electronic claim, the DMEPOS supplier will receive a rejection message on the CEDI GenResponse Report.

2. If the DMEPOS supplier claim is a paper CMS-1500 claim, the DMEPOS supplier will see the rejection indicated on the Remittance Advice.

• In both phases, Medicare will verify the NPI and the name of the ordering/referring provider reported on the ANSI X12N 837P standard electronic claim against PECOS.

• When furnishing names on the paper claims, be sure not to use periods or commas within the name. Hyphenated names are permissible.

• Providers who order or refer may want to verify their enrollment in PECOS. They may do so by accessing Internet-based PECOS at https://pecos. cms.hhs.gov/ pecos/login. do on the CMS website. Before using

Internet-based PECOS, providers should read the educational material about Internet-based PECOS that is available at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l/04_Internetbas edPECOS.asp on the CMS website. Once at that site, scroll to the downloads section of that page and click on the materials that apply to you and your practice.

 

============ ========= ========= ==

http://homecaremag. com/news/ pecos-medicare- 20091023/

 

snip/snip

Late last year, CMS rolled out its Internet-based PECOS, which allows physicians and other practitioners to enroll in Medicare, check on the status of an application or make a change in their enrollment information. But according to officials on the call, even if physicians are enrolled in Medicare but have not submitted any updates or changes to their enrollment record since 2003, it's likely their information won't be in the new system.

The January deadline concerns physician and non-physician practitioners who must be enrolled in PECOS. As of Oct. 5, if the ordering/referring physician on a claim is not in the system, or is in PECOS but not of the type/specialty to order or refer, the claim will continue to process — and the provider will receive a warning message from the Common Electronic Data Interchange (CEDI). Beginning Jan. 1, such claims will reject.

snip/snip

Physicians have 'no idea' what we're talking about

Question: I would just ask that continuing education go on with the physicians, because we have had the same thing that [Rose Schafhauser] mentioned when she called earlier. We are calling our physicians, and they have no idea what we are talking about.

Bossenmeyer: The question should be to the physician, 'Have you updated your enrollment information with Medicare since November 2003?' If they are a long-standing Medicare physician and have not made any changes in their enrollment information, they likely have not updated their information.

Question: The answer we are getting to that is 'Why is it any of your business? Why are you as a DME supplier telling us what to do?'

Bossenmeyer: Medicare will be raising this issue at the next physician Open Door Forum, and we will continue to educate physicians via conference calls and with our contractors to update and maintain their enrollment in the Medicare program.

Why should the burden fall on DME providers?

Question: Regarding the PECOS system, will the physician's claim also be rejected in January 2010 if they are not in the system?

Bossenmeyer: Physicians' claims will continue to be processed.

Question: Why are DME claims then being rejected?

Bossenmeyer: Medicare requires that we know who the physician is, that the physician is licensed and that they are qualified to continue to participate in the Medicare program. To implement that provision, physicians must be enrolled in Medicare with a current enrollment record within Medicare.

Question: So that burden falls on [DME providers] to make sure?

Bossenmeyer: Medicare will continue to conduct outreach to physicians. Again, there are only a limited number of nonphysician practitioners who are eligible, and those are physician assistants, certified clinical nurse specialists, nurse practitioners, clinical psychologists, certified nurse midwives and clinical social workers. So if you are receiving orders and referrals from nonphysician practitioners other than those, those will not be eligible for future payment beginning in January of next year.

How come physicians don't know they should register in PECOS?

Question: How have physicians been notified that they have to register with PECOS?

Bossenmeyer: CMS has encouraged physicians since November of 2006 to update their enrollment info with Medicare. We are doing revalidations where we are requiring physicians and other practitioners to update their Medicare enrollment information. If they do not respond to the revalidation, then Medicare would take some action to revoke their billing privileges.

Prior to the Q & A session, Bossenmeyer reminded providers that CR 6421 also requires that claims coming from DMEPOS suppliers must include the legal business name of the physician.

On the competitive bidding front, CMS' Kaiser, deputy director of DMEPOS policy, added that the bidding window for the Round 1 rebid closes on Dec. 21, and that Nov. 21 is the " covered document review date, " which is designed to motivate providers to turn in all financial documents no later than that date. If providers make the deadline, they will be notified of any missing documents. However, they will not be told if those documents are correct and/or filled out properly.

 

============ ========= ====

http://www.aanp. org/AANPCMS2/ LegislationPract ice/Regulation/ Medicare+ Provider+ Enrollment+ Chain+and+ Ownership+ System+PECOS+ Delay+in+ Implementing. htm

 

Although enrolled in Medicare, many physicians and non-physician practitioners who are eligible to order items or services or refer Medicare beneficiaries to other Medicare providers or suppliers for services do not have current enrollment records in Medicare.  A current enrollment record is one that is in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and also contains the physician/non- physician practitioner’ s National Provider Identifier (NPI).  Under Phase 2 of the above referenced CRs, a physician or non-physician practitioner who orders or refers and who does not have a current enrollment record that contains the NPI will cause the claim submitted by the Part B provider/supplier who furnished the ordered or referred item or service to be rejected. 

 

CMS continues to urge physicians and non-physician practitioners who are enrolled in Medicare but who have not updated their Medicare enrollment record since November 2003 to update their enrollment record now.  If these physicians and non-physician practitioners have no changes to their enrollment data, they need to submit an initial enrollment application which will establish a current enrollment record in PECOS.

 

For physicians and non-physician practitioners who order or refer—

 

•         If you are not enrolled in the Medicare program, or if you enrolled more than 6 years ago and have not submitted any updates or changes to your enrollment information in more than 6 years, you do not have an enrollment record in PECOS.  In order to continue to order or refer items or services for Medicare beneficiaries, you will have to submit an initial enrollment application.  You may do so either by (1) using Internet-based PECOS (which transmits your enrollment application to the Medicare carrier or A/B MAC via the Internet—be sure to mail the signed and dated Certification Statement to the carrier or A/B MAC immediately after submitting the application) , or (2) filling out the appropriate paper Medicare provider enrollment application( s) (CMS-855I and CMS-855R, if appropriate) and mailing the application, along with any required additional supplemental documentation, to the local Medicare carrier or A/B MAC, who will enter your information into PECOS and process your enrollment application.  Information on how to enroll in Medicare is found on the Medicare provider/supplier enrollment web site at www.cms.hhs. gov/MedicareProv iderSupEnroll.

•         If you are already enrolled in Medicare, make sure you have a current enrollment record.  You can find out if you have an enrollment record in PECOS by calling your designated carrier or A/B MAC or by going on-line, using Internet-based PECOS, to view your enrollment record.  We will be posting information to the Medicare provider/supplier enrollment web site that will guide you through this process.  Information about Internet-based PECOS and a link to Internet-based PECOS can be found on the Medicare provider/supplier enrollment web site. Before using Internet-based PECOS, we recommend that you read the information that is posted there and that is available in the downloadable documents section.

•         If you are a dentist or a physician with a specialty such as a pediatrics who is eligible to order or refer items or services for Medicare beneficiaries but have not enrolled in Medicare because the services you provide are not covered by Medicare or you treat few Medicare beneficiaries, you need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries.

•         If you are a physician who is employed by the Department of Veterans Affairs, the Public Health Service, or the Department of Defense Tricare program but have not enrolled in Medicare because you would not be paid by Medicare for your services, you need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries.

 

If you are a resident who has a medical license but have not enrolled in Medicare because you would not be paid by Medicare for your services, you do not need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries.  The teaching physician—not the resident—should be identified in claims as the ordering/referring provider when a resident orders or refers items or services for Medicare beneficiaries.

============ ========= ========= ==

http://www.lamedica re.com/provider/ viewarticle. aspx?articleid= 7578

Guidance on Using Internet-based Provider Enrollment, Chain and Ownership System (PECOS)Reference: SE0914Published Online: 8/5/2009

Printer Friendly Page | Back To Previous Page

Provider Types AffectedThis article is for physicians, non-physician practitioners, and organization providers and suppliers who are enrolled or wish to enroll in the Medicare program. NOTE: Suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) do not, at this time, have the option of using Internet-based PECOS. The availability of Internet-based PECOS to DMEPOS suppliers will be announced at a future date.

Provider Action NeededThis Special Edition (SE) 0914 article alerts physicians, non-physician practitioners, providers and suppliers that the Centers for Medicare & Medicaid Services (CMS) is reaching out to assist those providers and suppliers who wish to use Internet-based PECOS for enrollment in Medicare and/or to maintain the currency of the enrollment data they have on file with Medicare. Internet-based PECOS offers physicians, non-physician practitioners, and organization providers and suppliers a means of applying for enrollment and updating their enrollment information faster than the paper enrollment process that required the use of the paper CMS-855 series of forms. The documents that describe Internet-based PECOS are available at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l/04_Internetbas edPECOS.asp# TopOfPage on the CMS website. BackgroundInternet-based PECOS has been available to physicians and non-physician practitioners since December 2008, and to organization providers and suppliers since April 1, 2009. (As noted above, DMEPOS suppliers may not use the system at this time, but will be able to do so at a future date.) There are certain pre-requisites that must be met before one can use Internet-based PECOS. In addition, the processes for physicians and non-physician practitioners differ somewhat from those used by provider and supplier organizations. This article will present a high-level overview of these processes and will direct physicians, non-physician practitioners, providers, and organization providers and suppliers to other sources available via the Medicare Learning Network (MLN) that will enable them to learn more. An important benefit for all physicians, non-physician practitioners, and organization providers and suppliers is that Internet-based PECOS speeds up the completion of their initial Medicare enrollment application as well as the update of their enrollment information when changes occur. CMS timelines for Medicare contractors to process Internet-submitted enrollment applications are more stringent than those for paper:

Contractors must process 90 percent of web-based applications (e.g., initial enrollments and changes of information) within 45 days of receipt of the signed and dated Certification Statement and supporting documentation. Contractors must process 80 percent of initial paper applications within 60 days, and 80 percent of paper changes of information within 45 days.

With the temporary exception of the DMEPOS suppliers, physicians, non-physician practitioners, and organization providers and suppliers can use the Internet to enroll in Medicare, to update their existing enrollment information, to view their existing enrollment information, or to voluntarily terminate their Medicare enrollment. Once a provider or supplier submits an application via the web, the provider or supplier can view the status of that application beginning 15 days after the submission. (The 15-day time frame allows sufficient time for the Medicare enrollment contractor to have received the signed and dated Certification Statement and begin action on the application. More information about the Certification Statement will be supplied later in this article.)

One crucial point that physicians, non-physician practitioners, and organization providers and suppliers should understand is that, if they want to use Internet-based PECOS to update or view their Medicare enrollment information, or to terminate their enrollment in Medicare, they must first have an enrollment record in PECOS. If a physician, non-physician practitioner, or organization provider or supplier enrolled in Medicare more than 5 years ago and has not submitted any updates or changes to their enrollment record over the past 5 years, it is very likely that the provider or supplier is not in PECOS. If one of these providers or suppliers accesses Internet-based PECOS attempts to view or update the enrollment record, there will be nothing there to view or update. Providers and suppliers who find themselves in this situation will have to revalidate their enrollment with Medicare. In order to revalidate, the provider or supplier has to furnish all the information necessary to initially enroll in Medicare. This will get the provider or supplier into PECOS and will ensure that their enrollment information, which may have changed over the years, is current. If they never submitted the CMS-588 Electronic Funds Transfer Agreement, they will have to do so as part of the revalidation. Providers and suppliers can revalidate their enrollment via Internet-based PECOS or they can fill out the appropriate paper CMS-855 Medicare provider enrollment forms and mail them to the appropriate enrollment contractor.

The remainder of this article provides the overviews of the processes for using Internet-based PECOS and identifies other sources of information.

Physicians and Non-Physician PractitionersBefore a physician or non-physician practitioner initiates a Medicare enrollment action using Internet-based PECOS, he or she will need the following: An active National Provider Identifier (NPI); A National Plan and Provider Enumeration System (NPPES) User ID and password; Personal identifying information, which includes the physician’s or non-physician practitioner’ s legal name on file with the Social Security Administration, date of birth, and Social Security Number; Professional license and certification information, which includes information regarding the physician’s or non-physician practitioner’ s professional license, professional school degrees or certificates; Practice location information, which includes information regarding the physician’s or non-physician practitioner’ s medical practice location; The legal business name of a solely-owned Professional Association (PA), Professional Corporation (PC), or Limited Liability Company (LLC) on file with the Internal Revenue Service and appearing on the IRS CP575 form; A photocopy of the CP-575 form; The NPI of the PA, PC, or LLC; and Any Federal, State, and/or local (city/county) business licenses, certifications and/or registrations specifically required by that business to operate as a health care facility; and If applicable, information about any final adverse action that impacts the physician or non-physician practitioner.

Internet based PECOS can be accessed with the same User ID and password that a physician or non-physician practitioner uses for NPPES. If the physician or non-physician practitioner does not have an NPPES User ID and password and needs help in obtaining one, he or she may contact the NPI Enumerator at 1- or send an email to customerservice@ npienumerator. com on the Internet.

Note:CMS recommends that a physician or non-physician practitioner change his/her NPPES password before accessing Internet based PECOS for the first time and at least once a year thereafter. Although the User ID cannot be changed, the password should be changed periodically – at least once a year. If you need help in changing your password, contact the NPI Enumerator at 1- or send an email to customerservice@ npienumerator. com on the Internet. For physicians and non-physician practitioners, there are three basic steps to completing an enrollment action using Internet-based PECOS. Use your National Plan and Provider Enumeration System (NPPES) User ID and password to log on to Internet-based PECOS at https://pecos. cms.hhs.gov/ pecos/login. do ; Complete, review, and submit the electronic enrollment application via Internet-based PECOS; Print, sign and date the Certification Statement and mail the Certification Statement and all supporting paper documentation to the designated Medicare contractor within 7 days of electronic submission.

Note:A Medicare contractor will not process an Internet enrollment application without receipt of the signed and dated Certification Statement. In addition, the effective date of filing an enrollment application is the date the Medicare contractor receives the signed Certification Statement that is associated with the Internet-submitted application. The Certification Statement must be signed by the physician or non-physician practitioner enrolling or making changes to enrollment information. Signatures must be original and in ink (blue ink recommended) . Copied or stamped signatures or dates will not be accepted.

The physician or non-physician practitioner assumes full and complete liability for new and updated Medicare enrollment information that is transmitted to the enrollment contractor via Internet-based PECOS once the enrollment contractor receives the signed and dated Certification Statement.

While CMS encourages physicians and non-physician practitioners to print and retain a copy of the Internet-submitted enrollment application for their records, physicians and non-physician practitioners should only mail the Certification Statement and supporting documentation to the designated Medicare contractor. Do not mail the copy of the enrollment application to the designated Medicare contractor; to do so may delay the processing of the application.

For more information about Internet-based PECOS, along with questions and answers (Q & As), go to the Downloads section at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l/04_Internetbas edPECOS.asp# TopOfPage on the CMS website.

Provider and Supplier OrganizationsBefore a provider or supplier organization can use Internet based PECOS, the organization’ s Authorized Official must take the first step. Below is the process that occurs for an organization provider or supplier to gain access to Internet-based PECOS:

The organization provider/supplier’ s Authorized Official (AO) goes into PECOS I & A and registers. As part of this process, the AO must mail a photocopy of the CP-575 to the CMS EUS Help Desk so that the Help Desk can verify the organization provider/supplier. The Help Desk verifies both the organization provider/supplier and the AO, and approves the AO’s registration. The AO receives a system-generated e-mail indicating that the registration has been approved. Once the AO receives this notification, the AO can let the end-user know that he/she can register in PECOS. The end-user goes into PECOS I & A and registers. The registration request will be directed to the AO of the provider/supplier organization. The AO must approve or reject the end-user in PECOS I & A. Once the end-user has been approved in PECOS I & A by the AO for access on behalf of the organization provider/supplier, the end-user will receive a system-generated e-mail indicating that he/she has been approved. The end-user then logs into PECOS and downloads the Security Consent Form. He or she fills it out, obtains the signature/date of signature of the AO, and mails the completed Security Consent Form to the CMS EUS Help Desk at P.O. Box 792750, San , TX 78216. The Help Desk verifies the information on the Security Consent Form and also calls the AO to verify that the AO did, in fact, sign the Security Consent Form. Once the information on the security Consent Form has been confirmed, the Help Desk approves the Security Consent Form in PECOS and an e-mail is sent to the AO notifying the AO that the end user’s organization has been approved to use Internet-based PECOS on behalf of the organization provider/supplier. It is the AO’s responsibility to notify the end-user’s organization that the end-user can now use Internet-based PECOS. An e-mail is sent to the AO (step 9) because the AO is ultimately responsible for the enrollment information and who has access to that enrollment information. It is the AO’s responsibility to inform the end-user that the Security Consent Form has been approved.

Note:The Security Consent Form is completed only one time to establish the relationship between the provider or supplier organization and the employer organization whose employee(s) would submit enrollment applications on behalf of the provider or supplier organization. More than one individual may request access to Internet-based PECOS for a given provider or supplier organization, but the Security Consent Form is generated and completed by the first (if more than one) approved user who logs on to Internet-based PECOS to submit an enrollment application for the given provider or supplier organization. A Security Consent Form must be completed, signed and dated, and mailed to the CMS EUS Help Desk even if the employer organization is the provider or supplier organization. More detail about obtaining access to Internet-based PECOS for providers and suppliers can be found in the document entitled, " Getting Started with Internet-based Provider Enrollment, Chain and Ownership System (PECOS) – Information for Provider and Supplier Organizations, " along with Q & As is available at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l/Downloads/ OrganizationGett ingStarted. pdf on the CMS web site.

Limitations of Internet-based PECOS for Provider and Supplier OrganizationsThere are some scenarios that Internet-based PECOS cannot accommodate at this time; they will be available at a future date. These scenarios are: Changes in Taxpayer Identification Number (TIN). These must be done using the paper enrollment application (CMS-855). Changes in Legal Business Name (LBN). These must be done using the paper enrollment application (CMS-855). An enrolled Medicare Part A provider or supplier organization wants to enroll with a Medicare carrier or A/B Medicare Administrative Contractor (MAC) to bill for Part B services. This must be done using the paper enrollment application (CMS-855).

These scenarios are listed in the document entitled, " Overview of Internet-based Provider Enrollment, Chain and Ownership System (PECOS) – Information for Provider and Supplier Organizations, " available at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l/Downloads/ OrganizationOver view.pdf on the CMS website.

Additional InformationThe CMS External User Services (EUS) Help Desk contact information for providers and suppliers using Internet-based PECOS can be found at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l/Downloads/ ContactInformati on.pdf on the CMS website. The Help Desk hours of operation are Monday – Friday, from 6 a.m. to 6 p.m. Central Standard Time. The Help Desk toll-free number is 1- and their e-mail address is eussupportcgi (DOT) com. Questions about accessing and using Internet-based PECOS should be directed to the CMS EUS Help Desk. The overall CMS site regarding provider and supplier enrollment can be found at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l on the CMS website. From there, click on " Internet-based PECOS " on the left-hand side to go to information specific to Internet-based PECOS.

[Guest guest]

Monarch was terrible when I was in the big HMO world years ago, and hasn't improved from what I hear.  Greater Newport is much better.Sharon

[Guest guest]

Must be a SoCal thing. I’ve never heard

of SCAN…and we take ‘em all up here.

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Egly

Sent: Thursday, June 17, 2010 6:36

PM

To:

Subject: Re:

Problem With SCAN Newport

IPA or Monarch and Father-In-Law

Calafornia IMPs can you explain how to negotiate SCAN medicare HMO. My

father-in-law is 79 and has dementia, BPH, and prostate cancer.

He was a Long Beach GP from 1959 till 2005. He really needs a local

doctor to treat him the way he has been treated, but he has been run in circles

without helping him with post void dribbling. Primary MDs have granted

referrals to subspecialists but referrals denied. He lives in Newport Beach and comes with a wife who is 74

and has been a nurse since 1957. They need good IMPing care

to improve the quality of the remainder of their lives. Scan has

prevented them from transfering back to regular medicare since March, 2009.

Any suggestions would be appreciated. No one wants to see him

until he seperates from the HMO and IPA's

From: Locke

<lockecoloradogmail>

To: ;

Practice Management Issues <practicemgtlyris (DOT) aafp.org>

Sent: Wed, December 30, 2009

1:20:06 PM

Subject:

Provider Enrollment, Chain and Ownership System (PECOS) --> Re: Medicare's PECOS database [1 Attachment]

I'm still not sure I understand this.

Although, when I go to...

https://pecos.

cms.hhs.gov/ pecos/login. do

And log in using my NPI login I set up in the past --- same login used

at...

https://nppes.

cms.hhs.gov/ NPPES/Welcome. do

....I am in the system -- so apparently updated and OK.

But it's still confusing. Also, it sounds like the problems will come

down more on the Durable Medical Equipment DME suppliers (who will have their

claims rejected if the ordering provider isn't in the PECOS)

than on providers specifically.

This is probably the best explanation of why you (as medicare

provider) would want to make sure you are in PECOS -- basically, if you

order a lot of DME -- your suppliers (wheelchairs, oxygen supplies, etc) will

have their claims rejected and have to get you to update your information in

PECOS before they can get paid.

At least that is my take on everything.

============ ========= ===

http://www.oandp.

com/articles/ 2009-12_01. asp

According to the policy, in order for durable medical equipment, prosthetics,

orthotics, and supplies (DMEPOS) claims to be paid, the physician or

non-physician referrer/prescriber (described as the " ordering/referring

provider " ) must be enrolled in Medicare and registered on the database of

a program titled the Medicare Provider Enrollment, Chain, and Ownership System

(PECOS). The ordering/referring providers must be listed in the PECOS database with their individual National Provider

Identifier (NPI) number and must have enrolled or updated their entry in the

database since November 2003. Ordering/referring providers who were previously

not enrolled in Medicare, including those whose services are not covered by

Medicare, such as Department of Veterans Affairs (VA) and Public Health Service

physicians, are included in the mandate, and if they do not enroll in Medicare

and join the PECOS database, they will no longer be able to refer their

patients for DMEPOS through Medicare.

Physician

Complications

Stark, DMEPOS consultant and reimbursement specialist at MiraVista LLC, wrote

in a statement to her customers, " At this point, many referral sources

have obtained an NPI [through the NPPES system], but they may or may not have

registered with the PECOS system. To make

matters worse, many physicians remain unaware of the recent requirement to

enroll in PECOS, as their claims are not

likely to be affected by these new DME-specific edits. This enrollment process

appears to go more quickly for individual practitioners but can be a lengthy

process taking up to 60 days for organizational/ group practices. "

============

========= ========= ==

BTW,

horse's/medicare's mouth is below and attached...

http://www.cms. hhs.gov/MLNMatte rsArticles/ downloads/

MM6421.pdf

• During Phase 1

(October 5, 2009-April 4, 2010): If the ordering/referring provider is on the claim,

Medicare will verify that the ordering/referring provider is in PECOS and is eligible to order/refer in Medicare. If the ordering/referring provider is not in PECOS or

is in PECOS but is not of the type/specialty

to order or refer, the claim will continue to process.

1.

If the DMEPOS

supplier claim is an ANSI X12N 837P standard electronic claim, the DMEPOS

supplier will receive a warning message on the Common Electronic Data

Interchange (CEDI) GenResponse Report.

2. If the

DMEPOS supplier claim is a paper CMS-1500 claim, the DMEPOS supplier will not

receive a warning and will not know that the claim did not pass these edits.

•During Phase

2, (April 5, 2010 and thereafter): If the ordering/referring

provider is not on the claim, the claim will not be paid. If the

ordering/referring provider is on the claim, Medicare will verify that the

ordering/referring provider is in PECOS

and eligible to order and refer. If the

ordering/referring provider is not in PECOS or is in PECOS

but is not of the specialty to order or refer, the claim will not be paid.

It will be rejected.

1. If the DMEPOS supplier claim is an ANSI X12N

837P standard electronic claim, the DMEPOS supplier will receive a

rejection message on the CEDI GenResponse Report.

2. If the DMEPOS supplier claim is a paper CMS-1500

claim, the DMEPOS supplier will see the rejection indicated on the Remittance

Advice.

• In both phases,

Medicare will verify the NPI and the name of the ordering/referring

provider reported on the ANSI X12N 837P standard electronic claim against PECOS.

• When

furnishing names on the paper claims, be sure not to use periods or commas

within the name. Hyphenated names are permissible.

•

Providers who order or refer may want to verify their enrollment in PECOS. They may do so by accessing Internet-based PECOS at https://pecos.

cms.hhs.gov/ pecos/login. do on the CMS website. Before using

Internet-based

PECOS, providers should read the educational material about Internet-based PECOS that is available at http://www.cms. hhs.gov/Medicare ProviderSupEnrol

l/04_Internetbas edPECOS.asp on the CMS website.

Once at that site, scroll to the downloads section of that page and click on

the materials that apply to you and your practice.

============ ========= ========= ==

http://homecaremag. com/news/ pecos-medicare- 20091023/

snip/snip

Late last

year, CMS rolled out its Internet-based PECOS,

which allows physicians and other practitioners to enroll in Medicare, check on

the status of an application or make a change in their enrollment information.

But according to officials on the call, even if physicians are enrolled in

Medicare but have not submitted any updates or changes to their enrollment

record since 2003, it's likely their information won't be in the new system.

The

January deadline concerns physician and non-physician practitioners who must be

enrolled in PECOS. As of Oct. 5, if the

ordering/referring physician on a claim is not in the system, or is in PECOS

but not of the type/specialty to order or refer, the claim will continue to

process — and the provider will receive a warning message from the Common

Electronic Data Interchange (CEDI). Beginning Jan. 1, such claims will reject.

snip/snip

Physicians

have 'no idea' what we're talking about

Question:

I would just ask that continuing education go on with the physicians, because

we have had the same thing that [Rose Schafhauser] mentioned when she called

earlier. We are calling our physicians, and they have no idea what we are

talking about.

Bossenmeyer:

The question should be to the physician, 'Have you updated your enrollment

information with Medicare since November 2003?' If they are a long-standing

Medicare physician and have not made any changes in their enrollment

information, they likely have not updated their information.

Question:

The answer we are getting to that is 'Why is it any of your business? Why are

you as a DME supplier telling us what to do?'

Bossenmeyer:

Medicare will be raising this issue at the next physician Open Door Forum, and

we will continue to educate physicians via conference calls and with our

contractors to update and maintain their enrollment in the Medicare program.

Why

should the burden fall on DME providers?

Question:

Regarding the PECOS system, will the

physician's claim also be rejected in January 2010 if they are not in the

system?

Bossenmeyer:

Physicians' claims will continue to be processed.

Question:

Why are DME claims then being rejected?

Bossenmeyer:

Medicare requires that we know who the physician is, that the physician is

licensed and that they are qualified to continue to participate in the Medicare

program. To implement that provision, physicians must be enrolled in Medicare

with a current enrollment record within Medicare.

Question:

So that burden falls on [DME providers] to make sure?

Bossenmeyer:

Medicare will continue to conduct outreach to physicians. Again, there are only

a limited number of nonphysician practitioners who are eligible, and those are

physician assistants, certified clinical nurse specialists, nurse

practitioners, clinical psychologists, certified nurse midwives and clinical

social workers. So if you are receiving orders and referrals from nonphysician

practitioners other than those, those will not be eligible for future payment

beginning in January of next year.

How

come physicians don't know they should register in PECOS?

Question:

How have physicians been notified that they have to register with PECOS?

Bossenmeyer:

CMS has encouraged physicians since November of 2006 to update their enrollment

info with Medicare. We are doing revalidations where we are requiring

physicians and other practitioners to update their Medicare enrollment

information. If they do not respond to the revalidation, then Medicare would

take some action to revoke their billing privileges.

Prior to

the Q & A session, Bossenmeyer reminded providers that CR 6421 also requires

that claims coming from DMEPOS suppliers must include the legal business name

of the physician.

On the

competitive bidding front, CMS' Kaiser, deputy director of DMEPOS policy,

added that the bidding window for the Round 1 rebid closes on Dec. 21, and that

Nov. 21 is the " covered document review date, " which is designed to

motivate providers to turn in all financial documents no later than that date.

If providers make the deadline, they will be notified of any missing documents.

However, they will not be told if those documents are correct and/or filled out

properly.

============ ========= ====

http://www.aanp. org/AANPCMS2/ LegislationPract ice/Regulation/

Medicare+ Provider+ Enrollment+ Chain+and+ Ownership+ System+PECOS+ Delay+in+

Implementing. htm

Although

enrolled in Medicare, many physicians and non-physician practitioners who are

eligible to order items or services or refer Medicare beneficiaries to other

Medicare providers or suppliers for services do not have current enrollment

records in Medicare. A current enrollment record is one that is in the

Medicare Provider Enrollment, Chain and Ownership System (PECOS) and also

contains the physician/non- physician practitioner’ s National Provider

Identifier (NPI). Under Phase 2 of the above referenced CRs, a physician

or non-physician practitioner who orders or refers and who does not have a

current enrollment record that contains the NPI will cause the claim submitted

by the Part B provider/supplier who furnished the ordered or referred item or

service to be rejected.

CMS

continues to urge physicians and non-physician practitioners who are enrolled

in Medicare but who have not updated their Medicare enrollment record since

November 2003 to update their enrollment record now. If these physicians

and non-physician practitioners have no changes to their enrollment data, they

need to submit an initial enrollment application which will establish a current

enrollment record in PECOS.

For

physicians and non-physician practitioners who order or refer—

•

If you are not enrolled in the Medicare program, or if you enrolled more than 6

years ago and have not submitted any updates or changes to your enrollment

information in more than 6 years, you do not have an enrollment record in

PECOS. In order to continue to order or refer items or services for

Medicare beneficiaries, you will have to submit an initial enrollment

application. You may do so either by (1) using Internet-based PECOS

(which transmits your enrollment application to the Medicare carrier or A/B MAC

via the Internet—be sure to mail the signed and dated Certification Statement

to the carrier or A/B MAC immediately after submitting the application) , or

(2) filling out the appropriate paper Medicare provider enrollment application(

s) (CMS-855I and CMS-855R, if appropriate) and mailing the application, along

with any required additional supplemental documentation, to the local Medicare

carrier or A/B MAC, who will enter your information into PECOS and process your

enrollment application. Information on how to enroll in Medicare is found

on the Medicare provider/supplier enrollment web site at www.cms.hhs.

gov/MedicareProv iderSupEnroll.

•

If you are already enrolled in Medicare, make sure you have a current

enrollment record. You can find out if you have an enrollment record in

PECOS by calling your designated carrier or A/B MAC or by going on-line, using

Internet-based PECOS, to view your enrollment

record. We will be posting information to the Medicare provider/supplier

enrollment web site that will guide you through this process. Information

about Internet-based PECOS and a link to Internet-based PECOS

can be found on the Medicare provider/supplier enrollment web site. Before

using Internet-based PECOS, we recommend that

you read the information that is posted there and that is available in the

downloadable documents section.

•

If you are a dentist or a physician with a specialty such as a pediatrics who

is eligible to order or refer items or services for Medicare beneficiaries but

have not enrolled in Medicare because the services you provide are not covered

by Medicare or you treat few Medicare beneficiaries, you need to enroll in

Medicare in order to continue to order or refer items or services for Medicare

beneficiaries.

•

If you are a physician who is employed by the Department of Veterans Affairs,

the Public Health Service, or the Department of Defense Tricare program but

have not enrolled in Medicare because you would not be paid by Medicare for

your services, you need to enroll in Medicare in order to continue to order or

refer items or services for Medicare beneficiaries.

If you

are a resident who has a medical license but have not enrolled in Medicare

because you would not be paid by Medicare for your services, you do not need to

enroll in Medicare in order to continue to order or refer items or services for

Medicare beneficiaries. The teaching physician—not the resident—should be

identified in claims as the ordering/referring provider when a resident orders

or refers items or services for Medicare beneficiaries.

============

========= ========= ==

http://www.lamedica re.com/provider/ viewarticle.

aspx?articleid= 7578

Guidance on Using

Internet-based Provider Enrollment, Chain and Ownership System (PECOS)

Reference: SE0914

Published Online:

8/5/2009

Printer Friendly Page | Back To Previous

Page

Provider Types

Affected

This article is for physicians, non-physician

practitioners, and organization providers and suppliers who are enrolled or

wish to enroll in the Medicare program. NOTE:

Suppliers of durable medical equipment, prosthetics, orthotics, and supplies

(DMEPOS) do not, at this time, have the option of using Internet-based PECOS. The availability of Internet-based PECOS to DMEPOS suppliers will be announced at a future

date.

Provider Action Needed

This Special Edition (SE) 0914 article alerts physicians,

non-physician practitioners, providers and suppliers that the Centers for

Medicare & Medicaid Services (CMS) is reaching out to assist those

providers and suppliers who wish to use Internet-based PECOS for enrollment in

Medicare and/or to maintain the currency of the enrollment data they have on

file with Medicare. Internet-based PECOS offers physicians, non-physician

practitioners, and organization providers and suppliers a means of applying for

enrollment and updating their enrollment information faster than the paper

enrollment process that required the use of the paper CMS-855 series of forms.

The documents that describe Internet-based PECOS

are available at http://www.cms. hhs.gov/Medicare ProviderSupEnrol

l/04_Internetbas edPECOS.asp# TopOfPage on the CMS website.

Background

Internet-based PECOS has

been available to physicians and non-physician practitioners since December

2008, and to organization providers and suppliers since April 1, 2009. (As

noted above, DMEPOS suppliers may not use the system at this time, but will be

able to do so at a future date.) There are certain pre-requisites that must be

met before one can use Internet-based PECOS.

In addition, the processes for physicians and non-physician practitioners

differ somewhat from those used by provider and supplier organizations. This

article will present a high-level overview of these processes and will direct

physicians, non-physician practitioners, providers, and organization providers

and suppliers to other sources available via the Medicare Learning Network (MLN)

that will enable them to learn more.

An

important benefit for all physicians, non-physician practitioners, and

organization providers and suppliers is that Internet-based PECOS

speeds up the completion of their initial Medicare enrollment application as

well as the update of their enrollment information when changes occur. CMS

timelines for Medicare contractors to process Internet-submitted enrollment

applications are more stringent than those for paper:

Contractors must process 90

percent of web-based applications (e.g., initial enrollments and changes of

information) within 45 days of receipt of the signed and dated Certification

Statement and supporting documentation. Contractors must process 80 percent of

initial paper applications within 60 days, and 80 percent of paper changes of

information within 45 days.

With

the temporary exception of the DMEPOS suppliers, physicians, non-physician

practitioners, and organization providers and suppliers can use the Internet to

enroll in Medicare, to update their existing enrollment information, to view

their existing enrollment information, or to voluntarily terminate their

Medicare enrollment. Once a provider or supplier submits an application via the

web, the provider or supplier can view the status of that application beginning

15 days after the submission. (The 15-day time frame allows sufficient time for

the Medicare enrollment contractor to have received the signed and dated

Certification Statement and begin action on the application. More information

about the Certification Statement will be supplied later in this article.)

One

crucial point that physicians, non-physician practitioners, and organization

providers and suppliers should understand is that, if they want to use

Internet-based PECOS to update or view their Medicare enrollment information,

or to terminate their enrollment in Medicare, they must first have an

enrollment record in PECOS. If a physician,

non-physician practitioner, or organization provider or supplier enrolled in

Medicare more than 5 years ago and has not submitted any updates or changes to

their enrollment record over the past 5 years, it is very likely that the

provider or supplier is not in PECOS. If one

of these providers or suppliers accesses Internet-based PECOS attempts to view

or update the enrollment record, there will be nothing there to view or update.

Providers and suppliers who find themselves in this situation will have to

revalidate their enrollment with Medicare. In order to revalidate, the provider

or supplier has to furnish all the information necessary to initially enroll in

Medicare. This will get the provider or supplier into PECOS

and will ensure that their enrollment information, which may have changed over

the years, is current. If they never submitted the CMS-588 Electronic Funds

Transfer Agreement, they will have to do so as part of the revalidation.

Providers and suppliers can revalidate their enrollment via Internet-based PECOS or they can fill out the appropriate paper CMS-855

Medicare provider enrollment forms and mail them to the appropriate enrollment

contractor.

The

remainder of this article provides the overviews of the processes for using

Internet-based PECOS and identifies other

sources of information.

Physicians and Non-Physician

Practitioners

Before a physician or non-physician practitioner initiates

a Medicare enrollment action using Internet-based PECOS,

he or she will need the following:

An active National Provider

Identifier (NPI); A National Plan and Provider Enumeration System (NPPES) User

ID and password; Personal identifying information, which includes the

physician’s or non-physician practitioner’ s legal name on file with the Social

Security Administration, date of birth, and Social Security Number;

Professional license and certification information, which includes information

regarding the physician’s or non-physician practitioner’ s professional

license, professional school degrees or certificates; Practice location

information, which includes information regarding the physician’s or

non-physician practitioner’ s medical practice location; The legal business

name of a solely-owned Professional Association (PA), Professional Corporation

(PC), or Limited Liability Company (LLC) on file with the Internal Revenue

Service and appearing on the IRS CP575 form; A photocopy of the CP-575 form;

The NPI of the PA, PC, or LLC; and Any Federal, State, and/or local

(city/county) business licenses, certifications and/or registrations

specifically required by that business to operate as a health care facility;

and If applicable, information about any final adverse action that impacts the

physician or non-physician practitioner.

Internet

based PECOS can be accessed with the same User

ID and password that a physician or non-physician practitioner uses for NPPES.

If the physician or non-physician practitioner does not have an NPPES User ID

and password and needs help in obtaining one, he or she may contact the NPI

Enumerator at 1- or send an email to customerservice@ npienumerator.

com on the Internet.

Note:

CMS recommends that a physician or

non-physician practitioner change his/her NPPES password before accessing

Internet based PECOS for the first time and at

least once a year thereafter. Although the User ID cannot be changed, the

password should be changed periodically – at least once a year. If you need

help in changing your password, contact the NPI Enumerator at 1- or

send an email to customerservice@ npienumerator. com on the Internet.

For physicians and non-physician practitioners

, there are three basic steps to completing an enrollment

action using Internet-based PECOS.

Use your National Plan and

Provider Enumeration System (NPPES) User ID and password to log on to

Internet-based PECOS at https://pecos.

cms.hhs.gov/ pecos/login. do ; Complete, review, and submit the electronic

enrollment application via Internet-based PECOS;

Print, sign and date the Certification Statement and mail the Certification

Statement and all supporting paper documentation to the designated Medicare

contractor within 7 days of electronic submission.

Note:

A Medicare contractor will not process an Internet enrollment application without

receipt of the signed and dated Certification Statement. In

addition, the effective date of filing an

enrollment application is the date the Medicare contractor receives the signed

Certification Statement that is associated with the

Internet-submitted application.

The

Certification Statement must be signed by the physician or non-physician

practitioner enrolling or making changes to enrollment information. Signatures

must be original and in ink (blue ink recommended) . Copied or stamped

signatures or dates will not be accepted.

The

physician or non-physician practitioner assumes full and complete liability for

new and updated Medicare enrollment information that is transmitted to the

enrollment contractor via Internet-based PECOS

once the enrollment contractor receives the signed and dated Certification

Statement.

While

CMS encourages physicians and non-physician practitioners to print and retain a

copy of the Internet-submitted enrollment application for their records,

physicians and non-physician practitioners should only mail the Certification Statement and supporting documentation to the

designated Medicare contractor. Do not mail the copy of the enrollment

application to the designated Medicare contractor; to do so may delay the

processing of the application.

For

more information about Internet-based PECOS,

along with questions and answers (Q & As), go to the Downloads section at http://www.cms. hhs.gov/Medicare ProviderSupEnrol

l/04_Internetbas edPECOS.asp# TopOfPage on the CMS website.

Provider and Supplier Organizations

Before a provider or supplier organization can use

Internet based PECOS, the organization’ s Authorized Official must take the

first step. Below is the process that occurs for an organization

provider or supplier to gain access to Internet-based PECOS:

The organization provider/supplier’ s

Authorized Official (AO) goes into PECOS

I & A and registers. As part of this process, the AO must mail a

photocopy of the CP-575 to the CMS EUS Help Desk so that the Help Desk can

verify the organization provider/supplier.

The Help Desk verifies both the organization

provider/supplier and the AO, and approves the AO’s registration. The AO

receives a system-generated e-mail indicating that the registration has

been approved.

Once the AO receives this notification, the AO

can let the end-user know that he/she can register in PECOS.

The end-user goes into PECOS

I & A and registers. The registration request will be directed to the AO

of the provider/supplier organization.

The AO must approve or reject the end-user in PECOS I & A.

Once the end-user has been approved in PECOS

I & A by the AO for access on behalf of the organization

provider/supplier, the end-user will receive a system-generated e-mail

indicating that he/she has been approved.

The end-user then logs into PECOS

and downloads the Security Consent Form. He or she fills it out, obtains

the signature/date of signature of the AO, and mails the completed

Security Consent Form to the CMS EUS Help Desk at P.O. Box 792750, San ,

TX 78216.

The Help Desk verifies the information on the

Security Consent Form and also calls the AO to verify that the AO did, in

fact, sign the Security Consent Form.

Once the information on the security Consent

Form has been confirmed, the Help Desk approves the Security Consent Form

in PECOS and an e-mail is sent to the AO notifying the AO that the end

user’s organization has been approved to use Internet-based PECOS on behalf of the organization

provider/supplier.

It is the AO’s responsibility to notify the

end-user’s organization that the end-user can now use Internet-based PECOS. An e-mail is sent to the AO (step 9) because

the AO is ultimately responsible for the enrollment information and who

has access to that enrollment information. It is the AO’s responsibility

to inform the end-user that the Security Consent Form has been approved.

Note:

The Security Consent Form is completed

only one time to establish the relationship between the provider or supplier

organization and the employer organization whose employee(s) would submit

enrollment applications on behalf of the provider or supplier organization.

More than one individual may request access to Internet-based PECOS for a given

provider or supplier organization, but the Security Consent Form is generated

and completed by the first (if more than one) approved user who logs on to Internet-based

PECOS to submit an enrollment application for the given provider or supplier

organization. A Security Consent Form must be completed, signed and dated, and

mailed to the CMS EUS Help Desk even if the employer organization is the

provider or supplier organization.

More

detail about obtaining access to Internet-based PECOS

for providers and suppliers can be found in the document entitled,

" Getting Started with Internet-based Provider Enrollment, Chain and

Ownership System (PECOS) – Information for Provider

and Supplier Organizations, " along with Q & As is available

at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l/Downloads/

OrganizationGett ingStarted. pdf on the CMS web site.

Limitations of Internet-based PECOS for Provider and Supplier Organizations

There are some scenarios that Internet-based PECOS cannot accommodate at this time; they will be

available at a future date. These scenarios are:

Changes in Taxpayer Identification

Number (TIN). These must be done using the paper enrollment application

(CMS-855). Changes in Legal Business Name (LBN). These must be done using the

paper enrollment application (CMS-855). An enrolled Medicare Part A provider or

supplier organization wants to enroll with a Medicare carrier or A/B Medicare

Administrative Contractor (MAC) to bill for Part B services. This must be done

using the paper enrollment application (CMS-855).

These

scenarios are listed in the document entitled, " Overview of Internet-based

Provider Enrollment, Chain and Ownership System (PECOS) – Information for Provider and Supplier Organizations, "

available at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l/Downloads/

OrganizationOver view.pdf on the CMS website.

Additional Information

The CMS External User Services (EUS) Help Desk contact

information for providers and suppliers using Internet-based PECOS

can be found at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l/Downloads/

ContactInformati on.pdf on the CMS website. The Help Desk hours of

operation are Monday – Friday, from 6 a.m. to 6 p.m. Central Standard Time. The

Help Desk toll-free number is 1- and their e-mail address is eussupportcgi (DOT) com. Questions about

accessing and using Internet-based PECOS

should be directed to the CMS EUS Help Desk.

The

overall CMS site regarding provider and supplier enrollment can be found at http://www.cms.

hhs.gov/Medicare ProviderSupEnrol l on the CMS website. From there, click

on " Internet-based PECOS " on the left-hand side to go to information

specific to Internet-based PECOS.

[Guest guest]

me neither.. in socal

 

Must be a SoCal thing.  I’ve never heard of SCAN…and we take ‘em all up here.

 

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Egly

Sent: Thursday, June 17, 2010 6:36 PMTo:

Subject: Re: Problem With SCAN Newport IPA or Monarch and Father-In-Law

 

 

Calafornia IMPs can you explain how to negotiate SCAN medicare HMO. My father-in-law is 79 and has dementia, BPH, and prostate cancer.  He was a Long Beach GP from 1959 till 2005.  He really needs a local doctor to treat him the way he has been treated, but he has been run in circles without helping him with post void dribbling.  Primary MDs have granted referrals to subspecialists but referrals denied. He lives in Newport Beach and comes with a wife who is 74 and  has been a nurse  since 1957.  They need good IMPing care to improve the quality of the remainder of their lives.  Scan has prevented them from transfering back to regular medicare since March, 2009.

 

Any suggestions would be appreciated.  No one wants to see him until he seperates from the HMO and IPA's

 

 

 

To: ; Practice Management Issues

Sent: Wed, December 30, 2009 1:20:06 PMSubject: Provider Enrollment, Chain and Ownership System (PECOS) --> Re: Medicare's PECOS database [1 Attachment]

 

I'm still not sure I understand this.

Although, when I go to...

    

     https://pecos. cms.hhs.gov/ pecos/login. do

 

And log in using my NPI login I set up in the past --- same login used at...

 

     https://nppes. cms.hhs.gov/ NPPES/Welcome. do

 

....I am in the system -- so apparently updated and OK.

 

But it's still confusing. Also, it sounds like the problems will come down more on the Durable Medical Equipment DME suppliers (who will have their claims rejected if the ordering provider isn't in the PECOS) than on providers specifically.

 

This is probably the best explanation of why you (as medicare provider) would want to make sure you are in PECOS -- basically, if you order a lot of DME -- your suppliers (wheelchairs, oxygen supplies, etc) will have their claims rejected and have to get you to update your information in PECOS before they can get paid.

 

At least that is my take on everything.

 

============ ========= ===

http://www.oandp. com/articles/ 2009-12_01. asp

 

According to the policy, in order for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) claims to be paid, the physician or non-physician referrer/prescriber (described as the " ordering/referring provider " ) must be enrolled in Medicare and registered on the database of a program titled the Medicare Provider Enrollment, Chain, and Ownership System (PECOS). The ordering/referring providers must be listed in the PECOS database with their individual National Provider Identifier (NPI) number and must have enrolled or updated their entry in the database since November 2003. Ordering/referring providers who were previously not enrolled in Medicare, including those whose services are not covered by Medicare, such as Department of Veterans Affairs (VA) and Public Health Service physicians, are included in the mandate, and if they do not enroll in Medicare and join the PECOS database, they will no longer be able to refer their patients for DMEPOS through Medicare.

 

Physician Complications

Stark, DMEPOS consultant and reimbursement specialist at MiraVista LLC, wrote in a statement to her customers, " At this point, many referral sources have obtained an NPI [through the NPPES system], but they may or may not have registered with the PECOS system. To make matters worse, many physicians remain unaware of the recent requirement to enroll in PECOS, as their claims are not likely to be affected by these new DME-specific edits. This enrollment process appears to go more quickly for individual practitioners but can be a lengthy process taking up to 60 days for organizational/ group practices. "

============ ========= ========= ==

BTW, horse's/medicare's mouth is below and attached...

http://www.cms. hhs.gov/MLNMatte rsArticles/ downloads/ MM6421.pdf

• During Phase 1 (October 5, 2009-April 4, 2010): If the ordering/referring provider is on the claim, Medicare will verify that the ordering/referring provider is in PECOS and is eligible to order/refer in Medicare. If the ordering/referring provider is not in PECOS or is in PECOS but is not of the type/specialty to order or refer, the claim will continue to process.

1.

If the DMEPOS supplier claim is an ANSI X12N 837P standard electronic claim, the DMEPOS supplier will receive a warning message on the Common Electronic Data Interchange (CEDI) GenResponse Report.

2. If the DMEPOS supplier claim is a paper CMS-1500 claim, the DMEPOS supplier will not receive a warning and will not know that the claim did not pass these edits.

•During Phase 2, (April 5, 2010 and thereafter): If the ordering/referring provider is not on the claim, the claim will not be paid. If the ordering/referring provider is on the claim, Medicare will verify that the ordering/referring provider is in PECOS and eligible to order and refer. If the ordering/referring provider is not in PECOS or is in PECOS but is not of the specialty to order or refer, the claim will not be paid. It will be rejected.

1. If the DMEPOS supplier claim is an ANSI X12N 837P standard electronic claim, the DMEPOS supplier will receive a rejection message on the CEDI GenResponse Report.

2. If the DMEPOS supplier claim is a paper CMS-1500 claim, the DMEPOS supplier will see the rejection indicated on the Remittance Advice.

• In both phases, Medicare will verify the NPI and the name of the ordering/referring provider reported on the ANSI X12N 837P standard electronic claim against PECOS.

• When furnishing names on the paper claims, be sure not to use periods or commas within the name. Hyphenated names are permissible.

• Providers who order or refer may want to verify their enrollment in PECOS. They may do so by accessing Internet-based PECOS at https://pecos. cms.hhs.gov/ pecos/login. do on the CMS website. Before using

Internet-based PECOS, providers should read the educational material about Internet-based PECOS that is available at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l/04_Internetbas edPECOS.asp on the CMS website. Once at that site, scroll to the downloads section of that page and click on the materials that apply to you and your practice.

 

============ ========= ========= ==

http://homecaremag. com/news/ pecos-medicare- 20091023/

 

snip/snip

Late last year, CMS rolled out its Internet-based PECOS, which allows physicians and other practitioners to enroll in Medicare, check on the status of an application or make a change in their enrollment information. But according to officials on the call, even if physicians are enrolled in Medicare but have not submitted any updates or changes to their enrollment record since 2003, it's likely their information won't be in the new system.

The January deadline concerns physician and non-physician practitioners who must be enrolled in PECOS. As of Oct. 5, if the ordering/referring physician on a claim is not in the system, or is in PECOS but not of the type/specialty to order or refer, the claim will continue to process — and the provider will receive a warning message from the Common Electronic Data Interchange (CEDI). Beginning Jan. 1, such claims will reject.

snip/snip

Physicians have 'no idea' what we're talking about

Question: I would just ask that continuing education go on with the physicians, because we have had the same thing that [Rose Schafhauser] mentioned when she called earlier. We are calling our physicians, and they have no idea what we are talking about.

Bossenmeyer: The question should be to the physician, 'Have you updated your enrollment information with Medicare since November 2003?' If they are a long-standing Medicare physician and have not made any changes in their enrollment information, they likely have not updated their information.

Question: The answer we are getting to that is 'Why is it any of your business? Why are you as a DME supplier telling us what to do?'

Bossenmeyer: Medicare will be raising this issue at the next physician Open Door Forum, and we will continue to educate physicians via conference calls and with our contractors to update and maintain their enrollment in the Medicare program.

Why should the burden fall on DME providers?

Question: Regarding the PECOS system, will the physician's claim also be rejected in January 2010 if they are not in the system?

Bossenmeyer: Physicians' claims will continue to be processed.

Question: Why are DME claims then being rejected?

Bossenmeyer: Medicare requires that we know who the physician is, that the physician is licensed and that they are qualified to continue to participate in the Medicare program. To implement that provision, physicians must be enrolled in Medicare with a current enrollment record within Medicare.

Question: So that burden falls on [DME providers] to make sure?

Bossenmeyer: Medicare will continue to conduct outreach to physicians. Again, there are only a limited number of nonphysician practitioners who are eligible, and those are physician assistants, certified clinical nurse specialists, nurse practitioners, clinical psychologists, certified nurse midwives and clinical social workers. So if you are receiving orders and referrals from nonphysician practitioners other than those, those will not be eligible for future payment beginning in January of next year.

How come physicians don't know they should register in PECOS?

Question: How have physicians been notified that they have to register with PECOS?

Bossenmeyer: CMS has encouraged physicians since November of 2006 to update their enrollment info with Medicare. We are doing revalidations where we are requiring physicians and other practitioners to update their Medicare enrollment information. If they do not respond to the revalidation, then Medicare would take some action to revoke their billing privileges.

Prior to the Q & A session, Bossenmeyer reminded providers that CR 6421 also requires that claims coming from DMEPOS suppliers must include the legal business name of the physician.

On the competitive bidding front, CMS' Kaiser, deputy director of DMEPOS policy, added that the bidding window for the Round 1 rebid closes on Dec. 21, and that Nov. 21 is the " covered document review date, " which is designed to motivate providers to turn in all financial documents no later than that date. If providers make the deadline, they will be notified of any missing documents. However, they will not be told if those documents are correct and/or filled out properly.

 

============ ========= ====

http://www.aanp. org/AANPCMS2/ LegislationPract ice/Regulation/ Medicare+ Provider+ Enrollment+ Chain+and+ Ownership+ System+PECOS+ Delay+in+ Implementing. htm

 

Although enrolled in Medicare, many physicians and non-physician practitioners who are eligible to order items or services or refer Medicare beneficiaries to other Medicare providers or suppliers for services do not have current enrollment records in Medicare.  A current enrollment record is one that is in the Medicare Provider Enrollment, Chain and Ownership System (PECOS) and also contains the physician/non- physician practitioner’ s National Provider Identifier (NPI).  Under Phase 2 of the above referenced CRs, a physician or non-physician practitioner who orders or refers and who does not have a current enrollment record that contains the NPI will cause the claim submitted by the Part B provider/supplier who furnished the ordered or referred item or service to be rejected. 

 

CMS continues to urge physicians and non-physician practitioners who are enrolled in Medicare but who have not updated their Medicare enrollment record since November 2003 to update their enrollment record now.  If these physicians and non-physician practitioners have no changes to their enrollment data, they need to submit an initial enrollment application which will establish a current enrollment record in PECOS.

 

For physicians and non-physician practitioners who order or refer—

 

•         If you are not enrolled in the Medicare program, or if you enrolled more than 6 years ago and have not submitted any updates or changes to your enrollment information in more than 6 years, you do not have an enrollment record in PECOS.  In order to continue to order or refer items or services for Medicare beneficiaries, you will have to submit an initial enrollment application.  You may do so either by (1) using Internet-based PECOS (which transmits your enrollment application to the Medicare carrier or A/B MAC via the Internet—be sure to mail the signed and dated Certification Statement to the carrier or A/B MAC immediately after submitting the application) , or (2) filling out the appropriate paper Medicare provider enrollment application( s) (CMS-855I and CMS-855R, if appropriate) and mailing the application, along with any required additional supplemental documentation, to the local Medicare carrier or A/B MAC, who will enter your information into PECOS and process your enrollment application.  Information on how to enroll in Medicare is found on the Medicare provider/supplier enrollment web site at www.cms.hhs. gov/MedicareProv iderSupEnroll.

•         If you are already enrolled in Medicare, make sure you have a current enrollment record.  You can find out if you have an enrollment record in PECOS by calling your designated carrier or A/B MAC or by going on-line, using Internet-based PECOS, to view your enrollment record.  We will be posting information to the Medicare provider/supplier enrollment web site that will guide you through this process.  Information about Internet-based PECOS and a link to Internet-based PECOS can be found on the Medicare provider/supplier enrollment web site. Before using Internet-based PECOS, we recommend that you read the information that is posted there and that is available in the downloadable documents section.

•         If you are a dentist or a physician with a specialty such as a pediatrics who is eligible to order or refer items or services for Medicare beneficiaries but have not enrolled in Medicare because the services you provide are not covered by Medicare or you treat few Medicare beneficiaries, you need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries.

•         If you are a physician who is employed by the Department of Veterans Affairs, the Public Health Service, or the Department of Defense Tricare program but have not enrolled in Medicare because you would not be paid by Medicare for your services, you need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries.

 

If you are a resident who has a medical license but have not enrolled in Medicare because you would not be paid by Medicare for your services, you do not need to enroll in Medicare in order to continue to order or refer items or services for Medicare beneficiaries.  The teaching physician—not the resident—should be identified in claims as the ordering/referring provider when a resident orders or refers items or services for Medicare beneficiaries.

============ ========= ========= ==

http://www.lamedica re.com/provider/ viewarticle. aspx?articleid= 7578

Guidance on Using Internet-based Provider Enrollment, Chain and Ownership System (PECOS)

Reference: SE0914Published Online: 8/5/2009

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Provider Types Affected

This article is for physicians, non-physician practitioners, and organization providers and suppliers who are enrolled or wish to enroll in the Medicare program. NOTE: Suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) do not, at this time, have the option of using Internet-based PECOS. The availability of Internet-based PECOS to DMEPOS suppliers will be announced at a future date.

Provider Action Needed

This Special Edition (SE) 0914 article alerts physicians, non-physician practitioners, providers and suppliers that the Centers for Medicare & Medicaid Services (CMS) is reaching out to assist those providers and suppliers who wish to use Internet-based PECOS for enrollment in Medicare and/or to maintain the currency of the enrollment data they have on file with Medicare. Internet-based PECOS offers physicians, non-physician practitioners, and organization providers and suppliers a means of applying for enrollment and updating their enrollment information faster than the paper enrollment process that required the use of the paper CMS-855 series of forms. The documents that describe Internet-based PECOS are available at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l/04_Internetbas edPECOS.asp# TopOfPage on the CMS website.

Background

Internet-based PECOS has been available to physicians and non-physician practitioners since December 2008, and to organization providers and suppliers since April 1, 2009. (As noted above, DMEPOS suppliers may not use the system at this time, but will be able to do so at a future date.) There are certain pre-requisites that must be met before one can use Internet-based PECOS. In addition, the processes for physicians and non-physician practitioners differ somewhat from those used by provider and supplier organizations. This article will present a high-level overview of these processes and will direct physicians, non-physician practitioners, providers, and organization providers and suppliers to other sources available via the Medicare Learning Network (MLN) that will enable them to learn more.

An important benefit for all physicians, non-physician practitioners, and organization providers and suppliers is that Internet-based PECOS speeds up the completion of their initial Medicare enrollment application as well as the update of their enrollment information when changes occur. CMS timelines for Medicare contractors to process Internet-submitted enrollment applications are more stringent than those for paper:

Contractors must process 90 percent of web-based applications (e.g., initial enrollments and changes of information) within 45 days of receipt of the signed and dated Certification Statement and supporting documentation. Contractors must process 80 percent of initial paper applications within 60 days, and 80 percent of paper changes of information within 45 days.

With the temporary exception of the DMEPOS suppliers, physicians, non-physician practitioners, and organization providers and suppliers can use the Internet to enroll in Medicare, to update their existing enrollment information, to view their existing enrollment information, or to voluntarily terminate their Medicare enrollment. Once a provider or supplier submits an application via the web, the provider or supplier can view the status of that application beginning 15 days after the submission. (The 15-day time frame allows sufficient time for the Medicare enrollment contractor to have received the signed and dated Certification Statement and begin action on the application. More information about the Certification Statement will be supplied later in this article.)

One crucial point that physicians, non-physician practitioners, and organization providers and suppliers should understand is that, if they want to use Internet-based PECOS to update or view their Medicare enrollment information, or to terminate their enrollment in Medicare, they must first have an enrollment record in PECOS. If a physician, non-physician practitioner, or organization provider or supplier enrolled in Medicare more than 5 years ago and has not submitted any updates or changes to their enrollment record over the past 5 years, it is very likely that the provider or supplier is not in PECOS. If one of these providers or suppliers accesses Internet-based PECOS attempts to view or update the enrollment record, there will be nothing there to view or update. Providers and suppliers who find themselves in this situation will have to revalidate their enrollment with Medicare. In order to revalidate, the provider or supplier has to furnish all the information necessary to initially enroll in Medicare. This will get the provider or supplier into PECOS and will ensure that their enrollment information, which may have changed over the years, is current. If they never submitted the CMS-588 Electronic Funds Transfer Agreement, they will have to do so as part of the revalidation. Providers and suppliers can revalidate their enrollment via Internet-based PECOS or they can fill out the appropriate paper CMS-855 Medicare provider enrollment forms and mail them to the appropriate enrollment contractor.

The remainder of this article provides the overviews of the processes for using Internet-based PECOS and identifies other sources of information.

Physicians and Non-Physician Practitioners

Before a physician or non-physician practitioner initiates a Medicare enrollment action using Internet-based PECOS, he or she will need the following:

An active National Provider Identifier (NPI); A National Plan and Provider Enumeration System (NPPES) User ID and password; Personal identifying information, which includes the physician’s or non-physician practitioner’ s legal name on file with the Social Security Administration, date of birth, and Social Security Number; Professional license and certification information, which includes information regarding the physician’s or non-physician practitioner’ s professional license, professional school degrees or certificates; Practice location information, which includes information regarding the physician’s or non-physician practitioner’ s medical practice location; The legal business name of a solely-owned Professional Association (PA), Professional Corporation (PC), or Limited Liability Company (LLC) on file with the Internal Revenue Service and appearing on the IRS CP575 form; A photocopy of the CP-575 form; The NPI of the PA, PC, or LLC; and Any Federal, State, and/or local (city/county) business licenses, certifications and/or registrations specifically required by that business to operate as a health care facility; and If applicable, information about any final adverse action that impacts the physician or non-physician practitioner.

Internet based PECOS can be accessed with the same User ID and password that a physician or non-physician practitioner uses for NPPES. If the physician or non-physician practitioner does not have an NPPES User ID and password and needs help in obtaining one, he or she may contact the NPI Enumerator at 1- or send an email to customerservice@ npienumerator. com on the Internet.

Note:

CMS recommends that a physician or non-physician practitioner change his/her NPPES password before accessing Internet based PECOS for the first time and at least once a year thereafter. Although the User ID cannot be changed, the password should be changed periodically – at least once a year. If you need help in changing your password, contact the NPI Enumerator at 1- or send an email to customerservice@ npienumerator. com on the Internet.

For physicians and non-physician practitioners

, there are three basic steps to completing an enrollment action using Internet-based PECOS.

Use your National Plan and Provider Enumeration System (NPPES) User ID and password to log on to Internet-based PECOS at https://pecos. cms.hhs.gov/ pecos/login. do ; Complete, review, and submit the electronic enrollment application via Internet-based PECOS; Print, sign and date the Certification Statement and mail the Certification Statement and all supporting paper documentation to the designated Medicare contractor within 7 days of electronic submission.

Note:

A Medicare contractor will not process an Internet enrollment application without receipt of the signed and dated Certification Statement. In addition, the effective date of filing an enrollment application is the date the Medicare contractor receives the signed Certification Statement that is associated with the Internet-submitted application.

The Certification Statement must be signed by the physician or non-physician practitioner enrolling or making changes to enrollment information. Signatures must be original and in ink (blue ink recommended) . Copied or stamped signatures or dates will not be accepted.

The physician or non-physician practitioner assumes full and complete liability for new and updated Medicare enrollment information that is transmitted to the enrollment contractor via Internet-based PECOS once the enrollment contractor receives the signed and dated Certification Statement.

While CMS encourages physicians and non-physician practitioners to print and retain a copy of the Internet-submitted enrollment application for their records, physicians and non-physician practitioners should only mail the Certification Statement and supporting documentation to the designated Medicare contractor. Do not mail the copy of the enrollment application to the designated Medicare contractor; to do so may delay the processing of the application.

For more information about Internet-based PECOS, along with questions and answers (Q & As), go to the Downloads section at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l/04_Internetbas edPECOS.asp# TopOfPage on the CMS website.

Provider and Supplier Organizations

Before a provider or supplier organization can use Internet based PECOS, the organization’ s Authorized Official must take the first step. Below is the process that occurs for an organization provider or supplier to gain access to Internet-based PECOS:

The organization provider/supplier’ s Authorized Official (AO) goes into PECOS I & A and registers. As part of this process, the AO must mail a photocopy of the CP-575 to the CMS EUS Help Desk so that the Help Desk can verify the organization provider/supplier.

The Help Desk verifies both the organization provider/supplier and the AO, and approves the AO’s registration. The AO receives a system-generated e-mail indicating that the registration has been approved.

Once the AO receives this notification, the AO can let the end-user know that he/she can register in PECOS.

The end-user goes into PECOS I & A and registers. The registration request will be directed to the AO of the provider/supplier organization.

The AO must approve or reject the end-user in PECOS I & A.

Once the end-user has been approved in PECOS I & A by the AO for access on behalf of the organization provider/supplier, the end-user will receive a system-generated e-mail indicating that he/she has been approved.

The end-user then logs into PECOS and downloads the Security Consent Form. He or she fills it out, obtains the signature/date of signature of the AO, and mails the completed Security Consent Form to the CMS EUS Help Desk at P.O. Box 792750, San , TX 78216.

The Help Desk verifies the information on the Security Consent Form and also calls the AO to verify that the AO did, in fact, sign the Security Consent Form.

Once the information on the security Consent Form has been confirmed, the Help Desk approves the Security Consent Form in PECOS and an e-mail is sent to the AO notifying the AO that the end user’s organization has been approved to use Internet-based PECOS on behalf of the organization provider/supplier.

It is the AO’s responsibility to notify the end-user’s organization that the end-user can now use Internet-based PECOS. An e-mail is sent to the AO (step 9) because the AO is ultimately responsible for the enrollment information and who has access to that enrollment information. It is the AO’s responsibility to inform the end-user that the Security Consent Form has been approved.

Note:

The Security Consent Form is completed only one time to establish the relationship between the provider or supplier organization and the employer organization whose employee(s) would submit enrollment applications on behalf of the provider or supplier organization. More than one individual may request access to Internet-based PECOS for a given provider or supplier organization, but the Security Consent Form is generated and completed by the first (if more than one) approved user who logs on to Internet-based PECOS to submit an enrollment application for the given provider or supplier organization. A Security Consent Form must be completed, signed and dated, and mailed to the CMS EUS Help Desk even if the employer organization is the provider or supplier organization.

More detail about obtaining access to Internet-based PECOS for providers and suppliers can be found in the document entitled, " Getting Started with Internet-based Provider Enrollment, Chain and Ownership System (PECOS) – Information for Provider and Supplier Organizations, " along with Q & As is available at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l/Downloads/ OrganizationGett ingStarted. pdf on the CMS web site.

Limitations of Internet-based PECOS for Provider and Supplier Organizations

There are some scenarios that Internet-based PECOS cannot accommodate at this time; they will be available at a future date. These scenarios are:

Changes in Taxpayer Identification Number (TIN). These must be done using the paper enrollment application (CMS-855). Changes in Legal Business Name (LBN). These must be done using the paper enrollment application (CMS-855). An enrolled Medicare Part A provider or supplier organization wants to enroll with a Medicare carrier or A/B Medicare Administrative Contractor (MAC) to bill for Part B services. This must be done using the paper enrollment application (CMS-855).

These scenarios are listed in the document entitled, " Overview of Internet-based Provider Enrollment, Chain and Ownership System (PECOS) – Information for Provider and Supplier Organizations, " available at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l/Downloads/ OrganizationOver view.pdf on the CMS website.

Additional Information

The CMS External User Services (EUS) Help Desk contact information for providers and suppliers using Internet-based PECOS can be found at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l/Downloads/ ContactInformati on.pdf on the CMS website. The Help Desk hours of operation are Monday – Friday, from 6 a.m. to 6 p.m. Central Standard Time. The Help Desk toll-free number is 1- and their e-mail address is eussupportcgi (DOT) com. Questions about accessing and using Internet-based PECOS should be directed to the CMS EUS Help Desk.

The overall CMS site regarding provider and supplier enrollment can be found at http://www.cms. hhs.gov/Medicare ProviderSupEnrol l on the CMS website. From there, click on " Internet-based PECOS " on the left-hand side to go to information specific to Internet-based PECOS.

 

-- Sangeetha Murthy M.D

[Guest guest]

and Sangeetha, maybe you guys have just been lucky to avoid them:

 

SCAN Medicare Advantage Plans

SCAN Health Plan is a California based " Medicare Advantage " HMO. SCAN serves the following counties:  LA, Orange, San Diego, Contra Costa, Kern, Riverside, San Bern, San Francisco, San Joaquin, Santa Clara, Ventura.

In US News and World Report's annual " Best Health Plans 2007 " SCAN Health Plan scored a 63.1 (out of 100) and finished a distant 8th, when compared to Medicare HMOs in California.

The top 5 Medicare HMOs in California were: Kaiser Permanente of Southern California (85.4), Kaiser Permanente of Northern California (83.7), Health Net of California (80.1), Pacificare of California (78.0) and Blue Shield of California (77.2).

 

 

http://www.scanhealthplan.com

 

 

 

They started off trying be a " social HMO " http://goliath.ecnext.com/coms2/gi_0198-27856/Independent-living-SCAN-Health-Plan.html  : 

 

" A unique social HMO for Medicare eligibles, SCAN goes beyond medical benefits and is able to offer its members access to community-based services such as transportation, housecleaning and home-delivered meals dessert included.  It's one of only four social HMOs in the country; and its mission centers on enabling its frail elderly population to live independently in lieu of more costly nursing homes. "  

 

That was from 2004, and I don't know if they are still trying to do that.

 

In 2008, they expanded to Arizona.

 

Sharon McCoy MD

Renaissance Family Medicine

10 McClintock Court; Irvine, CA  92617

PH: (949)387-5504   Fax: (949)281-2197  Toll free phone/fax:  

www.SharonMD.com

 

[Guest guest]

Since we’re not in any of those

counties, I guess we were able to avoid them.  We have a lot of patients on the

HealthNet plan through our IPA.  We get paid IPA rates for them, which is about

105% of Medicare.

Pratt

Office Manager

Oak Tree Internal Medicine P.C

www.prattmd.info

From: [mailto: ] On Behalf Of Sharon McCoy

Sent: Friday, June 18, 2010 9:34

AM

To:

Subject: Re:

Problem With SCAN Newport

IPA or Monarch and Father-In-Law

and Sangeetha, maybe you guys have just been lucky to avoid them:

SCAN

Medicare Advantage Plans

SCAN

Health Plan is a California

based " Medicare Advantage " HMO. SCAN serves the following

counties: LA, Orange, San Diego, Contra Costa, Kern, Riverside, San Bern,

San Francisco, San Joaquin, Santa Clara, Ventura.

In US

News and World Report's annual " Best Health Plans 2007 " SCAN Health

Plan scored a 63.1 (out of 100) and finished a distant 8th, when compared to

Medicare HMOs in California.

The top 5 Medicare HMOs in California

were: Kaiser Permanente of Southern California (85.4), Kaiser Permanente of Northern California (83.7), Health Net of California

(80.1), Pacificare of California (78.0) and Blue Shield of California (77.2).

http://www.scanhealthplan.com

They started off trying be a " social HMO " http://goliath.ecnext.com/coms2/gi_0198-27856/Independent-living-SCAN-Health-Plan.html

:

" A unique social HMO for Medicare eligibles, SCAN goes beyond

medical benefits and is able to offer its members access to community-based

services such as transportation, housecleaning and home-delivered meals dessert

included. It's one of only four social HMOs in the country; and its

mission centers on enabling its frail elderly population to live independently

in lieu of more costly nursing homes. "

That was from 2004, and I don't know if they are still trying to do

that.

In 2008, they expanded to Arizona.

Sharon

McCoy MD

Renaissance Family Medicine

10 McClintock Court;

Irvine, CA

92617

PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax:

www.SharonMD.com

[Guest guest]

I am a soon-to-be-former provider for Monarch IPA and I second Sharon 's

comment. I am restricted by contract from saying anything else (which you can

draw your own negative or positive conclusions from). Medicare advantage plans

keep members in by making them less desirable (on paper) to other plans (avoid

competition).

Maybe getting some of the chronic medical conditions off the record would help.

>

> Since we're not in any of those counties, I guess we were able to avoid

> them. We have a lot of patients on the HealthNet plan through our IPA. We

> get paid IPA rates for them, which is about 105% of Medicare.

>

>

>

>

>

>

>

> Pratt

>

> Office Manager

>

> Oak Tree Internal Medicine P.C

>

> www.prattmd.info

>

> _____

>

> From:

> [mailto: ] On Behalf Of Sharon McCoy

>

> Sent: Friday, June 18, 2010 9:34 AM

> To:

> Subject: Re: Problem With SCAN Newport IPA or Monarch

> and Father-In-Law

>

>

>

>

>

>

> and Sangeetha, maybe you guys have just been lucky to avoid them:

>

>

>

>

>

>

> SCAN Medicare Advantage Plans

>

>

> SCAN Health Plan is a California based " Medicare Advantage " HMO. SCAN serves

> the following counties: LA, Orange, San Diego, Contra Costa, Kern,

> Riverside, San Bern, San Francisco, San Joaquin, Santa Clara, Ventura.

>

> In US News and World Report's annual " Best Health Plans 2007 " SCAN Health

> Plan scored a 63.1 (out of 100) and finished a distant 8th, when compared to

> Medicare HMOs in California.

>

> The top 5 Medicare HMOs in California were: Kaiser Permanente of Southern

> California (85.4), Kaiser Permanente of Northern California (83.7), Health

> Net of California (80.1), Pacificare of California (78.0) and Blue Shield of

> California (77.2).

>

>

>

>

>

> http://www.scanheal <http://www.scanhealthplan.com/> thplan.com

>

>

>

>

>

>

>

> They started off trying be a " social HMO " http://goliath.

> <http://goliath.ecnext.com/coms2/gi_0198-27856/Independent-living-SCAN-Healt

> h-Plan.html>

> ecnext.com/coms2/gi_0198-27856/Independent-living-SCAN-Health-Plan.html :

>

>

>

> " A unique social HMO for Medicare eligibles, SCAN goes beyond medical

> benefits and is able to offer its members access to community-based services

> such as transportation, housecleaning and home-delivered meals dessert

> included. It's one of only four social HMOs in the country; and its mission

> centers on enabling its frail elderly population to live independently in

> lieu of more costly nursing homes. "

>

>

>

> That was from 2004, and I don't know if they are still trying to do that.

>

>

>

> In 2008, they expanded to Arizona.

>

>

>

> Sharon McCoy MD

>

> Renaissance Family Medicine

>

> 10 McClintock Court; Irvine, CA 92617

>

> PH: (949)387-5504 Fax: (949)281-2197 Toll free phone/fax:

>

> www.SharonMD. <http://www.SharonMD.com> com

>