PECOS: Medicare Referral Rules Change

Provider Enrollment, Chain and Ownership System (PECOS) rules finalized by the Centers for Medicare & Medicaid Services (CMS) will make it easier for physicians to refer patients to specialists.

The PECOS rules, published April 27 in the Federal Register, loosen proposed rules regarding referrals to specialists, freeing providers and Medicare patients from referrals in most cases. The rules also clarify the relationship between PECOS and the National Provider Identifier (NPI): PECOS being defined as an enrollment repository for Medicare, while the NPI database is a repository of information regarding all providers, regardless of their relationship with Medicare.

The new rule also allows physicians who are already registered with legacy Medicare systems to be able to serve and refer Medicare patients before they are registered in PECOS.

According to American Medical Association’s (AMA’s), CMS first outlined new enrollment rules for ordering and referring physicians in 2009, but stopped short of enforcing those requirements because as many as 200,000 doctors and other health care professionals (out of about 750,000) did not have enrollment records in PECOS.

In 2010, Congress required the use of NPIs for ordering and referring physicians on claims for medical equipment or services from laboratories, imaging providers, and suppliers. CMS later issued an interim regulation requiring all physicians who order supplies or refer services, including those from specialists, to be enrolled in PECOS by July 2010. CMS later delayed enforcement of that rule as the agency worked to validate and update enrollment records. Enforcement would have meant that claims for items or services would be rejected unless the ordering or referring physician also was in the enrollment system, not just the physician who provided the care.


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