HFMA Comments on Transition to HIPAA Eligibility Transaction System

March 19, 2015

Andrew Slavitt
Acting Administrator
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Avenue, SW, Room 310G
Washington, DC 20201  

Re:  Transition to HIPAA Eligibility Transaction System  

Dear Mr. Slavitt:  

The Healthcare Financial Management Association (HFMA) would like to thank the Centers for Medicare & Medicaid Services (CMS) for the opportunity to proactively comment on issues related to the transition from the Common Working File to the HIPAA Eligibility Transaction System.  

HFMA is a professional organization of more than 40,000 individuals involved in various aspects of healthcare financial management. HFMA is committed to helping its members improve the management of healthcare delivery systems, comply with the numerous rules and regulations that govern the industry, and further the principles of administrative simplification. Fraud and abuse in the healthcare system has an enormous adverse impact on healthcare quality and safety, while also imposing higher costs on consumers, employers, and taxpayers. We must develop and maintain a system that strikes the right balance between preventing fraud and other improper payments, and ensuring that providers are paid accurately and fairly for critical healthcare services furnished to beneficiaries.  

A vital part of ensuring an accurate payment system is providing access to the CMS claims and eligibility data. Providers frequently use this information to perform self-audits for the purposes of confirming compliance and correcting claims.  

At present, hospitals and other providers are allowed to access the Common Working File (CWF) to confirm beneficiary eligibility for billing purposes, and there is currently no practical time limit on how far a provider can go back to research this information. However, under Medicare’s reopening rules, providers only have four years to reopen a claim for purposes of correcting the claim.  

Alternatively, since 2005, providers have the ability to use either the HIPPA Eligibility Transaction System (HETS) or the CWF to query and reopen claims to ensure accurate billing. More recently, CMS announced that it will eliminate the CWF query capability and require use of HETS for preparing accurate Medicare claims or determining eligibility for specific services.  

CMS announced, through a technical “Release Summary” dated September 2014, that it will be reducing access to HETS eligibility data to 12 months from the date of service. The document attributes the modification to the need “to mirror the Medicare Fee-For-Service timely filing requirements” in the Affordable Care Act (ACA).  

We are concerned that the new HETS 12-month limitation will inhibit providers’ ability to review claims to ensure that their acute-care claims are reimbursed correctly. While we understand the intent to align access to eligibility data with the ACA’s timely filing requirements, we are concerned that a 12-month look-back window will not allow providers the time they are legally allotted to research facts and, if mistakes are discovered, reopen claims with Medicare under CMS’ reopening regulations. Further, using the best data available to them—which would not include access to beneficiary eligibility data through HETS— providers would be justifiably concerned about being subject to potential fraud and abuse exposure because, were they to seek reopening of past claims, they would be deprived of access to CMS–verified data to support their reopening request.  

Additionally, CMS contractors (such as Recovery Audit Contractors, or RACs) that review claims for accuracy and Medicare overpayments will not be subject to these same date-of-service data restrictions. RACs will still be permitted to go back three years to audit and will have access to the eligibility data needed to investigate potential overpayments and underpayments.

In order to ensure a level playing field, where providers have the same ability as the RACs to pursue an incorrect payment and to ensure that providers can legitimately pursue reopening during the period allowed in the regulations, we urge you to permit providers a three-year window of access to Medicare eligibility data, aligning with the access that the RACs enjoy.  

We support efforts to develop and maintain a system that strikes the right balance between preventing fraud and other improper payments, and ensuring that providers are paid accurately and fairly for critical healthcare services furnished to Medicare beneficiaries. No matter the root cause, overpayments to providers by Medicare represent funds that should be returned to the Medicare Trust Fund. At the same time, underpayments by Medicare to providers impact those providers’ financial viability and their ability to continue providing needed care to Medicare beneficiaries.  

We are at your service to help CMS gain a balanced perspective on this complex issue. If you have additional questions, you may reach me or Richard Gundling, Vice President of HFMA’s Washington, DC, office, at (202) 296-2920. The Association and I look forward to working with you.  

Sincerely,

Joseph J. Fifer, FHFMA, CPA
President and Chief Executive Officer
Healthcare Financial Management Association

About HFMA

With more than 40,000 members, the Healthcare Financial Management Association (HFMA) is the nation’s premier membership organization for healthcare finance leaders. HFMA builds and supports coalitions with other healthcare associations and industry groups to achieve consensus on solutions for the challenges the U.S. healthcare system faces today. Working with a broad cross-section of stakeholders, HFMA identifies gaps throughout the healthcare delivery system and bridges them through the establishment and sharing of knowledge and best practices. We help healthcare stakeholders achieve optimal results by creating and providing education, analysis, and practical tools and solutions. Our mission is to lead the financial management of health care.