Carriers will have to adjust to massive info demands
Carriers will have to adjust to massive info demands
Privatization, competition, downsizing
Given the amount of time and money many practices are spending these days to add bells and whistles to their information systems, it shouldn’t be a big surprise that some major changes in the way your Medicare carrier manages claims processing and review are coming over the next four years.
HCFA is revamping its current electronic data interchange system into a more encompassing second generation called the Medicare Transaction System (MTS).
HCFA experts say adapting your systems to HCFA’s new information system will have welcome benefits for physicians, such as:
• improved access to computerized claims information, such as beneficiary eligibility, pending claims status, payment decisions, and HMO enrollment/disenrollment;
• automatic coordination of benefits between Medicare and other insurers;
• more consistent implementation of new national payment coverage policies.
But things aren’t stopping here, says the AMA’s Medical Practice Financing and Systems Group on Health Policy and Financing.1 This group’s special task is to work with HCFA on carrier relationships. In a report provided to the Mississippi State Medical Society in Harrisburg, the AMA committee points out these changes in carrier information systems:
• The use of a national provider identifier (NPI). This will be required of physicians by July 1997, although some expect a grace period for more experienced physicians.
• The use of a national payer identifier, and a related database of private-payer data. This will be called PAYERID and is expected to be required by July 1997.
• New explanation of benefits (EOB) form. The new EOB will be called a Medicare Summary Notice. It will be a single form, and will contain complete information on a beneficiary’s Medicare transactions during a particular month, including all paid bills, coordination of other insurance claims sent for payment, and enrollment status. There is no release date set for this form.
• Integration of Part A, Part B, and Medicare managed care plans into one system. This change is scheduled to begin in late 1997, with full implementation by late 1999.
• Fewer claims carriers. All automated claims processing and related activities will be consolidated and processed at only two processing centers. This will replace the varied claims processing systems now used via EDI. This change is scheduled to begin in late 1997, with full implementation by late 1999.
Paper claims will continue to be processed at the local carrier level, but with the vast reduction in paper claims, many carriers may choose not to renew their contracts with Medicare, resulting in fewer carriers servicing larger regions of the country.
• Privatization of some local carrier review and claims processing functions. HCFA officials have expressed strong interest in having more flexibility in who HCFA can contract with. Currently, Part B claims must be processed by health insurers, and Part A claims must be processed by an insurer nominated by health care providers.
HCFA is pushing toward being able to contract with other organizations for process and/or review, and experts expect this to be part of Medicare reform proposals for 1997-98. Federal officials hope they can bid these services to a broader range of candidates and push for lower costs.
Facts about new ID numbers
Here are key facts about the two new ID umbers:
• National provider identifier (NPI). You may be using this already, although it isn’t required until July 1, 1997. Some physicians have multiple Medicare numerical identifiers, as well as other numerical identifiers assigned by private health plans. For example, physicians who serve Medicare patients have to use their UPIN (unique physician identification number), but they also must use a carrier-assigned billing number on the Medicare claim form. HCFA’s new system combines these two identifiers, and it will also offer the numbers to private insurers and encourage all payers to adopt them universally.
The NPI will serve as both unique identifier and as a billing number. Physicians will keep their assigned NPI throughout their careers, even if they change specialties or relocate their practice. This identifier will be linked through an electronic database maintained by HCFA that includes information such as name, address, specialty, type of practice, education, credentials, and any sanctions against the physician.
The NPI system is part of an intergovernmental effort to identify providers across programs. Other federal programs will be using them, too, such as CHAMPUS, Medicaid, Veterans Affairs, and the Federal Employees Benefits Program.
• National payer identifiers, or PAYERID. HCFA also is launching a major initiative to assign a unique identifier to all payers of health care claims to standardize and simplify benefits coordination. Payers currently are identified by Medicare in multiple ways, which can result in errors and delays, particularly in the Medicare Secondary Payor (MSP) and Medigap programs. In these programs, Medicare and private payers have to work out their shared levels of payment responsibilities.
PAYERID will form a national electronic database containing unique identifiers for all payers. This will allow Medicare to track beneficiary coverage by other insurers and better coordinate benefits with state Medicaid programs.
To try to simplify things, HCFA will give Medigap insurers identifiers containing certain digits that will be identify them as Medigap payers.
Current plans call for physicians to obtain access to the PAYERID database primarily through the health care network operations, claims clearinghouses, and large payers. The AMA, too, is exploring the possibility of HCFA developing a directory of payer identifiers that would be available to physicians who do not subscribe to a claims clearinghouse, or who would just like to have it as a handy reference.
Reference
1. AMA Medical Practice Financing and Systems Group on Health Policy. The changing role of Medicare carriers. Journal of the Mississippi State Medical Association 1996; 9:743-746.
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