What Is PECOS?
Traditionally there were two ways for a provider to enroll in Medicare: through mailed-in paperwork or through the online enrollment management system called the Provider Enrollment, Chain, and Ownership System, also known as PECOS.
As of January 6, 2014, the Centers for Medicare and Medicaid Services (CMS) began to deny claims for Medicare home health services or supplies from all physicians not registered in PECOS. CMS will increasingly deny claims of providers not enrolled in PECOS. In order to assure that your patients can receive the care and supplies they need, physicians who care for Medicare patients should enroll or renew their enrollment in PECOS.
With PECOS, providers may make the following changes to Medicare registration:
- Enroll as a Medicare provider or supplier
- Revalidate (renew) your enrollment
- Withdraw from the Medicare program
- Review and update your information
- Report changes to your enrollment record
- Electronically sign and submit your information
Can PECOS Status Change?
Yes! The Affordable Care Act requires that providers and suppliers revalidate their enrollment information under new enrollment screening criteria. Additionally, every three to five years, CMS Medicare Administrative Contractors will ask providers to update their enrollment application.
To find out if providers are actively enrolled, the Medicare Revalidation Lookup Tool will search providers’ status. If the tool displays “TBD” the provider is currently active and is not required to renew enrollment. However, if a provider’s due date is listed, the renewal should be submitted within six months of that date. This database should be regularly monitored.
Data Accuracy Between Providers & CMS
It is highly recommended that providers and suppliers who care for Medicare patients keep their information (address and location, etc.) current in PECOS. Although paper enrollments are still accepted, status changes or errors will be delayed if the internet-based PECOS is not used.
Providers must report a change of ownership or control, a change in practice location, and any final adverse legal actions such as revocations or suspensions of a Federal or State license within 30 days of the reportable change. This also includes physicians who are providing telemedicine services from their homes or alternate locations. All other changes may be submitted within 90 days.
CMS is temporarily ceasing revalidation efforts for all Medicare providers. If your revalidation is due soon, you will have to wait until the COVID-19 public health emergency is lifted. CMS will resume revalidation activities at that time.
Who Needs to Register for PECOS?
All physicians and practitioners who provide Medicare services to beneficiaries must enroll in PECOS to receive reimbursement. These providers include:
- Physicians and Specialists
- Registered Nurses
- Physician Assistants
- Certified Clinical Nurse Specialists
- Nurse Practitioners
- Clinical Psychologists
- Certified Nurse Midwives
- Clinical Social Workers
- Physicians employed by the Department of Veterans Affairs, the Public Health Service, or the Department of Defense
What Happens If A Provider Doesn’t Register In PECOS?
If a provider does not register in PECOS, reimbursement for Medicare claims and services will be denied and Medicare may no longer cover prescribed drugs. Although the provider may order and refer, they cannot bill for Medicare services. This may also cause delays in discharging patients and also means that they may be denied services or items needed for care. Providers should submit completed enrollment applications with adequate time for processing as verification may be required from third party sources.
What PECOS Sources Should Be Monitored?
The PECOS database is updated bi-weekly. To confirm the enrolled status of providers consult the Medical Provider and Supplier file. It is also critical to monitor National Provider Identifier (NPI) status and the CMS Preclusion List.
The Inaccuracies of PECOS
PECOS’s primary function is to facilitate Medicare provider enrollment. Although it is the first line of defense to mitigate fraudulent provider enrollment, multiple concerns have been raised around inaccurate reporting. The OIG has repeatedly reported inaccurate data via the PECOS system citing discrepancies between the limited data sources.
In order to collect comprehensive, trusted data healthcare organizations should take multiple steps to verify provider information. In order to verify provider credentials for accurate PECOS enrollment healthcare providers must:
- Use multiple data sources. No healthcare data set is comprehensive. Multiple state and federal databases such as state licensing boards, sanction and debarment lists, and more must be thoroughly checked.
- Verify cross-referenced identifiers. There are no standardized unique identifiers. Correctly identifying and verifying a provider’s identity is key.
- Recognize that each data source uses different categories and definitions.
Verisys Screens and Continuously Monitors PECOS
The steps necessary to verify and monitor provider information in PECOS adds considerable labor and expense to healthcare organizations’ schedules and budgets. To streamline the verification process, healthcare administrators should automate this process through software that continuously monitors thousands of databases. FACIS by Verisys is the gold-standard in provider data. Verisys regularly checks over 5,000 primary sources, including PECOS, to ensure that your providers are always in compliance. With trusted Verisys software, your healthcare organization will feel secure and confident in your provider PECOS enrollments and renewals.
|Written by Juliette Willard
Healthcare Communications Specialist
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