The “Sticky” NOE Problem

MEDTranDirect is a vendor of Medicare connectivity services, including access to the CMS HETS system (HIPAA Eligibility Transaction System) that provides real time eligibility data for healthcare organizations.  The data processed through this system is intended to provide a complete picture of all beneficiary data necessary to determine if payment will be received when healthcare services are provided to Medicare patients.

Late last year, we found a problem in the HETS data where the hospice NOE (Notice of Election) data was only present part of the time when it was processed in the CWF (Common Working File).  We documented this issue and reported it to HETS support.  Their initial response was that this was not a claim and that is why it was not showing up.  This did not make much sense since it did show up at least half of the time.  We resubmitted the problem again in February of this year, their response at that time was that it did not show up because the data was not in the CWF and the problem was with the MACs processing the NOEs and not the HETS system.  This conclusion was also not supported by the data we provided since we gave them screenshots of NOEs entered and accepted in DDE (Direct Data Entry), but were not present in HETS several days later.

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The Recovery Audit Program: The Big Business of Medicare Audits

The MACs (Medicare Administrative Contractors) audit claims submitted by providers within their jurisdictions.  These organizations are mostly insurance companies who administer the contracts awarded by CMS to process claims submitted electronically by providers in a given geographic area.   As part of this responsibility, these MACs are required to make sure that the claims submitted are complete and submitted in accordance with the rules developed by Medicare to assure that these claims are for services that are medically necessary and properly documented.

They work similar to the IRS, examining submitted claim data for outliers and patterns of suspicious behavior.   Like the IRS, they perform this service as part of their contractual obligation to the government, not as a revenue generating activity.

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