Healthcare Provider Solutions

The answer is – it depends. There is no Medicare requirement specific to hospices needing to ensure hospice medical directors/physicians or hospice patients’ attending physicians need to be enrolled in PECOS. This does not mean that hospice physicians should not be enrolled, however. Provisions of the Affordable Care Act require all providers of medical or other items or services and suppliers that qualify for a National Provider Identifier (NPI) to include their NPI on all applications to enroll in the Medicare and Medicaid programs and on all claims for payment submitted under the Medicare and Medicaid programs. In addition, it requires physicians and other professionals who are permitted to order and certify covered items and services for Medicare beneficiaries to be enrolled in Medicare. As stated above, CMS does not currently require hospices to ensure physicians are enrolled in PECOS.

There is a Medicare requirement, though, that hospice physicians and nurse practitioners (NPs) may need to comply with if they prescribe certain medications. CMS will require Medicare Part D prescribers to have an enrollment or valid opt-out record with CMS which will impact some hospice physicians and nurse practitioners (NP) who prescribe medications for hospice patients that are unrelated to a hospice plan of care and that are billed to Medicare Part D.

CMS has delayed implementation of this requirement twice in the past but has a solid final implementation date of January 1, 2019. However, certain prescribers may need to comply sooner as there are tiered deadlines with the final deadline being January 1, 2019. The tiered implementation plan can be viewed at the CMS Fact Sheet on the matter. Hospice agencies are not required to check for the NPI number nor the physician’s or NP’s Medicare provider number for Part D prescribers. More information about Part D prescriber PECOS enrollment/valid opt-out requirements for Medicare can be found here.

As a result of the provisions of the Affordable Care Act, Medicaid programs began requiring that physicians and some other professionals who order, prescribe, or refer Medicaid recipients for medical services or supplies be enrolled in the state’s Medicaid program. Some Medicaid managed care plans require the same. Therefore, hospice physicians and NPs in most states must meet this requirement. Hospices should refer to their state’s Medicaid program for more information.