Is it HETS or miss?

In a recent issue of CMS’s Medicare Learning Network Matters News Flash, SE 1249, CMS reaffirmed its intention to replace the Common Working File (CWF) Medicare beneficiary health insurance eligibility queries with HIPAA Eligibility Transaction System (HETS). (You can refer to last year’s blog posting for more details.) However, CMS has opted to postpone (again) the CWF access termination – this time indefinitely, but with a caveat. While this announcement will not affect the use of DDE to submit claims or to correct claims and will not impact access to beneficiary eligibility information, providers “should immediately begin transitioning to the Medicare Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System (HETS).”

Succinctly put, “While termination was originally scheduled for April 2014, CMS is delaying the date. CMS will provide at least 90 days advanced notice of the new termination date.”

So, in other words, transition to HETS sooner than later or you are at risk of missing out. Borrowing from our earlier blog, at some point in time you will no longer be able to check on a resident’s Medicare eligibility through the Common Working File (CWF).  HETS is replacing CWF inquiries. In a way, CMS has made life much easier for billers, because with HETS you can check a beneficiary’s eligibility in real time. CMS has simplified the eligibility checking process so that through HETS you can submit your inquiry with a real-time 270 request and receive your 271 response, a Functional Acknowledgement (999), an Interchange Acknowledgement (TA1), or a proprietary error response over a secure connection. According to the guide, “The information included in the 271 response is not intended to provide a complete representation of all benefits, but rather to address the status of eligibility (active or inactive) and patient financial responsibility for Medicare Part A and Part B.” This change will likely require you to change your billing processes.

Some of the information HETS will reveal to you will be in a format somewhat different from what you may be used to. Also, HETS will eventually be able to send Hospice information in the same format as the CWF. The HETS 270/271 Companion Guide gives you more insight into the eligibility information you will receive in the HETS 271 response.

ProClaim Partners offers direct access to HETS through its enterprise-class automated claims clearinghouse portal. Not only can you submit, monitor, and correct claims, if necessary, you can also determine a Medicare beneficiary’s eligibility. You can select exactly what information you want to see. There is no need to bounce between applications; your information regarding all things Medicare and other insurance payers is conveniently accessible in your own branded portal.

Question: If you are using HETS, how has this changed how you check a resident’s eligibility?

For some providers, billing can simply be a nightmare. Despite the countless years of experience in dealing with Medicare, insurance companies, and other claim problems, many still struggle with the complexities that go into billing. As a vital component in managing a business, it is crucial to learn some of the best billing practices which have been tested by professionals in the field.

1. Eligibility verification – By pre-screening a resident/patient’s insurance a provider can know upfront what can be covered and what will not. This will decrease the number of denials a provider receives when filling claims.
2. Admissions– Define a clear set of rules and follow them. These will help the patient and family to know up front how business will be conducted. Having a clear system of handling transactions allows you to save countless hours of financial reviews.
3. Revenue cycle – Create a revenue cycle and live by it. This will help guarantee that you get paid in a timely manner. Map out each step in the billing cycle and educate all the employees involved on how to properly handle their individual roles. While an educated staff can develop these, many providers might consider it valuable to bring in an expert like an accountant to help develop this cycle.

These are just a few of the countless practices that experts have found to increase billing efficiency. For more information, contact the experts at ProClaim Partners, who can show you how to make sure your business stays productive and profitable.

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