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Written by: Darlene D'Altorio-Jones (1959-2015) on Tuesday, July 2, 2013 Posted in: Outpatient Rehab

As all things non-HIPAA compliant, change is inevitable. It has been a long arduous process for the government to truly enact all portions of the administrative simplification act; 17 years to be precise as I discussed in a January blog. Continuously and FINALLY we are reaching the non-ending reform to improve privacy of protected information. Just recently that included the closing of the previously well-known and used CWF or Common Working File or ELGB (eligibility query for Medicare beneficiaries).

The Centers for Medicare and Medicaid Services had to eliminate the CWF capability because it was not HIPAA compliant.  They state in the change request provided in November of 2012 that ingoing and outgoing responses were not appropriately formatted to protect privacy. All information shared by covered entities for the purpose of sharing data for payment had to conform to the required HIPAA specifications. With this, we must learn a new tool and a new acronym. The CWF has been replaced by the HIPAA Eligibility Transaction System or HETS.

The HIPAA Eligibility Transaction System is intended to allow the release of eligibility data to Medicare providers, suppliers or their authorized billing agents for the purpose of preparing an accurate Medicare claim, determining beneficiary liability or determining eligibility for specific services. Such information may not be disclosed to anyone other than the provider, supplier or beneficiary for whom a claim is filed,” as stated by at their educational Web page on the topic.

I felt this information was of particular interest for all providers working very hard to continually keep up with the month-to-month eligibility of patients that may be on their treatment list, as well as monitor when that beneficiary may have reached the therapy cap limit for their annual allowance. Since providers may be required to provide an advanced beneficiary notice should they approach the cap limit, yet determine services should still be provided to the beneficiary; it is important for the provider to disclose to the beneficiary that these services will still be reviewed by a third party CMS contractor and that they may not agree with the continued services provided.

All services provided over the cap will be reviewed by the Medicare Audit Contractor with either a pre-payment or post-payment process completion. Without a pre-approval process or an exceptions policy in effect for continued treatment, services may still be denied despite the provider’s attempt to document reasonable and necessary provision of services. Either way, services will be provided first and the decision for payment will occur after an additional development request. Most importantly, the provider must keep a vigilante tab on the level of payment that has been paid from the beneficiary’s allotment at any given time for Medicare Part B services that fiscal year.

If you haven’t connected with beneficiary eligibility and payment information with the new HETS system, the referenced link will provide you all the details to sign up and more fully control your level of liability.

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