CMS – Medicare A & B Audit – IMPORTANT MUST READ

Over the past few months we have been communicating concerns from CMS related to the volume of eligibility transactions processed through the Medicare system (HETS)  on the 1^st of the month. There are two areas of concern from CMS that we want to bring your attention to:

• Volume of transactions submitted to CMS on the 1^st of the month and/or the 1^st Monday of the month between the hours of 7Am -7PM EST.
• Volume of repetitive transactions that have the same NPI and HIC number submitted on the same day. CMS currently has the threshold targeted at 30 transactions with this combination.

CMS notified us of a New AUDIT process that will begin with transactions submitted on October 1^s. These audits may result in the suspension of an NPI being able to submit eligibility requests until a Corrective Action Plan is submitted and approved by CMS.

 What is Experian Health  doing to address CMS concerns:

• Batch files sent to Experian Health on the 1^st of the month or 1^st Monday of the month will be held until after 7PM for processing through Medicare. Please know that your responses may be delayed based on these changes.
• We will be reaching out to providers who have been identified by CMS in the top 50 NPI’s sending eligibility transactions on the 1^st or 1^st Monday of the month, to discuss alternative workflows.
• Our technical teams are working to reduce multiple transactions for the same NPI/HICN combination.

What can you do to address CMS concerns:

• Any Batch file scheduled to be sent on the 1^st or  1^st Monday of the Month should be rescheduled to process later in the evening, after 7:00 PM EST or another day.
• CMS is asking that all non-urgent (non-urgent can be considered a patient is not seeking care the same day) eligibility transactions not be submitted on the 1^st or 1^st Monday of the month between the hours of 7AM-7PM ET.
• Providers who are manually submitting eligibility transactions should not submit the same NPI/HICN combination more than 25 times on the same day.

These initiatives should improve the performance of  Medicare’s eligibility processing until they can release their new system estimated to be late 2016.

If you want to read the notifications we received from CMS in their entirety please click on the link below

https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/HETSHelp/MCARE-Notification-Archive.html

Our account managers are reaching out to clients that have been flagged by CMS as high submitters, but please feel free to contact your account manager, sales representative, or customer support with any questions about how this may apply to your account.  We can work with you to adjust your EV submission rules if necessary.