CMS 837i and NOE Tracker – A Process Comparison

NOETracker
CMS 837I vs. NOETracker

On July 27, 2017, CMS issued Change Request 10064 describing a new process for submitting NOEs. This system, to be introduced in January of 2018, will allow hospices to use their billing software to create special claim files in the ANSI 837i format that contain NOE information.

The MACs will then receive these files just as they do actual claims. When they arrive, they will strip out the non-NOE data and post what would normally have been keyed into the FISS system as if it had been done manually through DDE. From this point, the transaction will be processed identically regardless of which method was used to deliver it, the 837i or DDE.

CMS developed this solution with help from NAHC. It is a significant effort to provide a path for providers and their vendors to develop solutions that could reduce the financial impact of keying errors that cause a majority of the rejected NOEs and associated penalties.

The idea of this project is to create a new “front end” to the FISS system, replacing the DDE screens with an industry standard record layout that could be used to submit this data system to system, as is done with claims.

The way the data will be delivered is through the 837i. This specification has been the required standard for all hospice claims (Institutional Provider Claims) for the last twenty years. This process, if implemented as it was intended, would provide two opportunities for validating the NOE data. First, by the vendor when the 837i is created, then by CMS when the claim batch is edited and a 277CA claim status report is returned. The data entry process through DDE has no edits to verify data entered manually.

On the surface, the idea seems simple enough. However, actually implementing it will not be easy.

First, creating the 837i. This transaction is used to send claim data to health plans for payment. It is created by most providers through their patient accounting systems or EMR. For hospices, it is usually processed on a monthly basis or when patients are discharged. The data used in this transaction is normally collected and verified after admission. With the NOE, the transaction must be sent immediately, as soon as the data is ready. If it is not sent within five days of admission, the provider is subject to non-covered services.

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Healthcare Analytics: Exploring Data on Providers and the Industry

Data analytics is a hot topic in the healthcare industry. However, people throw this term around with little understanding of what it really means. Similar to “Big Data” and “Affordable Healthcare”, it is difficult to know what people mean when the term can be applied to a wide variety of actual definitions that can be very different from each other.

For me, what differentiates analytics from other types of data reporting and analysis is how the topic or subject of the analysis is determined. In conventional data analysis, a report is developed to collect and format data in a manner pre-determined to address a specific issue or purpose. For example, you may develop a report that shows you the balance of your accounts receivables and to categorize these dollars into aging categories. This report allows you to get a current picture of how much money you are owed and by which health plans or patients. It allows you to focus on the money that is in danger of becoming uncollectable and to monitor your performance regarding this process over time. Similar reports are familiar to providers like census reports that show you admission and discharge activity and case mix reports that show you the clinical conditions associated with your patients.

healthcare-analytics-img

These reports are normally run in conjunction with other management activities where tasks are involved that take action based on this data or the data is used to adjust the distribution of resources. They become a part of the operational management plan for the healthcare organization.

In analytics, you build a pool of data without a specific purpose in mind. At this stage, the objective is to get clean, reliable and timely information from whatever sources are available. These can be the clinical systems under the control of the healthcare provider that can provide detailed information about encounters with their own patients or data that is available to the industry that is collected outside of these systems, both of these sources are essential to building a database that reflects the performance of the provider and an environment for comparing or benchmarking this data against the rest of the industry.

Once you have access to this data, in analytics, instead of developing a report to provide you with specific information, you examine the data itself for clues and relationships that will guide you through a process of exploring these discoveries. True analytics is more like science than accounting.

One method of data analysis is to develop a hypothesis and then use the data to prove or disprove the hypothesis. This is done by taking the hypothesis in question and converting it into an actionable query of the data. For example, let’s say that Medicare is introducing a new value-based payment model for the services your facility provides. Your question might be “How will this new payment model affect my Medicare revenue?” You might guess that your revenue might decrease, since this is the normal result of these changes, but it is not always the case.

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Back to Work – Reconnecting with the NOE Processing Problem

Hello everyone. First, I apologize for the long break in blog activity. A year ago, I retired as president of MEDTranDirect. I am grateful for the year off and the opportunity to get some perspective on my life and lower my golf handicap. Now it is time to get back to work.

Now that I am back, I see that there has been significant progress in my absence. CMS no longer depends on ancient computer systems for processing NOEs and claim data. Provider payments and adjustments are made fairly based on logical and actionable data. Attachments can be included in claim data so they no longer have to be re-associated after the fact. All remittances are sent electronically and there is a national database for insurance eligibility verification. Just kidding….

As all of you know, I didn’t really miss much. In reviewing regulatory changes while I was gone, nothing really stands out to me that would change how home care and other providers operate their organizations. However, this article would not prove useful if we did not discuss something relevant, so I would like to talk about CMS policy changes that took effect in December of 2016 regarding the processing of NOE (Notice of Election) transactions.

These changes are described in this MLN Matters article SE1633: here.

In this article, CMS admits that when “inadvertent errors” occur in the entry of the NOE, such as “transposing numbers in the HICN or provider ID”, this is not identified in the system until days later when the transaction is finally processed and classified as RTP (Returned to Provider).

This often, almost always, means that the opportunity to submit a valid NOE within the required five day window is lost.

To address this issue, instead of correcting errors in the DDE system, CMS has created a new procedure for hospices to work around these errors and document them when they occur. Like the original NOE transaction issues, the burden is on the hospice to identify the problem, enter a corrected NOE within two business days of the RTP, and document the issue through the remarks section of the first claim for the patient. If the condition that created the invalid NOE was due to a data entry error that should have been detectable by any adequate computer program, then the burden is on the hospice to prove this fact through this process. If the documentation is deemed accurate and complete after review by the MAC, they can reverse the unbilled days penalty for this claim for this reason.

This document from PGBA describes your options for dealing with each error that could occur during the entry of the NOE and if it falls within these guidelines for 2 day resubmission: read more.

These errors include every single data element keyed in the NOE. In my opinion, the significant aspect of these policy changes is that CMS is finally admitting that their own processing delays and inefficient systems are responsible for a large part of the problems associated with late NOE unbilled days and the labor intensive procedures surrounding the processing of this transaction. Unfortunately, their solution is to expand the procedures dealing with monitoring, correcting and resubmitting these errors instead of preventing them in the first place.

Although this policy change grants some relief financially, it increases the burden on hospices to execute and monitor these NOE transactions by adding new steps to the process that not only delay the processing of NOE’s, but also the first claims submitted for these patients.

If you ever tire of this process as a hospice agency, please check out our NOE Tracker which prevents NOE entry errors and monitors their progress.

Notice of Election Tracker

By Kalon Mitchell – President, MEDTranDirect

A Summary of Pre-Claim Review for Home Health Agencies

By now, home health agencies are well aware of the new program under development by CMS to crack down on what they believe is a major problem with improper payments for their services.  This is referred to as the “Pre-Claim Review Demonstration”.

This document describes these new regulations that were published in the Federal Register in June.

This effort is a drastic attempt by CMS to reduce the increasing improper payment rates associated directly with home health services.  Essentially, developing a process to examine 100% of all claims submitted by Home Health Agencies (HHA) prior to their approval and final payment.

Pre Claims Review for Home Health

CMS’s Comprehensive Error Rate Testing (CERT) program annually estimates the percentage of payments that did not meet Medicare coverage, coding and billing rules.  For 2015, they calculated the improper payment rate for home health claims at 59%.  This compares to 51.4% in 2014 and 17.3% in 2013.  CERT determined that a majority of errors that occurred in 2014 were due to the fact that the narrative documentation associated with face-to-face encounters did not support the patient’s homebound status and the need for skilled services.  Now CMS no longer requires separate narrative documentation for the face-to-face, but they are still seeing many cases where the documentation provided by the HHA in the medical record does not support the home health benefit they are providing.  These improper payments do not necessarily indicate fraud, it may simply be a lack of documentation, documentation errors, or a lack of understanding of Medicare rules.  However, fraud is a substantial contributor to the problem.

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MEDTranDirect Takes on Late NOEs with the New NOE Tracker

Since October of 2014, timely filing of NOE/NOTRs (Notice of Election/Notice of Termination-Revocation) has been a leading issue for the hospice industry.  As a software company that works on Medicare electronic transaction processing, when these regulations were announced, they caught our attention as a possible opportunity for a new product that might resolve some of the issues that CMS and the hospice industry dealt with regarding the efficiency of these transactions.

Notice of Election Tracker

One of the most difficult tasks you deal with regarding developing new software solutions is understanding the actual issues involved with a process and what the problems really are for the entities involved.  When these regulations were announced, it was clear that CMS felt that it was important to get these transactions submitted within five days.  This told us two things.   First, they were not being processed within this window a substantial portion of the time and second, that this delay presented problems for CMS and the industry.

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Healthcare Analytics – Analyzing the Cookie Jar

Healthcare analytics can be used to identify successful treatments, control costs, and make processes more efficient.  It can also be used to shed light on practices and industry relationships that might not be considered entirely healthy for the industry as a whole.

It is no secret that drug manufacturers make payments or provide services to physicians in an effort to strengthen their relationship with these providers.  Providers have long argued that these practices in no way influence their decision on which drugs they prescribe to their patients.

ProPublica, (www.propublica.org) an internet news site, has used this public data to create a database on providers and how much they collect through these payments from drug and medical device manufacturers.  They have made this database available through their site and you can look up the payments reported as paid to your physicians from these vendors.

analytics cookie jar

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Seasonal Discharge Rates for Hospices

As we discussed in my last article, the ACA has allowed CMS to explore new payment models that might more accurately reflect the value or cost of the services rendered by healthcare providers.  For acute care facilities, we are experiencing the beginnings of value-based payments intended to blend outcome data with billed services to determine fair compensation.

For hospices, new payment models have been introduced this year that are an attempt to more accurately reflect the cost of treating these patients at various stages of care.  The hospice payment changes are an attempt to match the “cost curve” where patient care costs more in the early days of treatment and the final days of life compared to the days in between.  This study was used to document these “curved” resources and provide the basis for the current payment model:

Cost Curve Study

Seasonal Blog Picture

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Value-Based Payments Can and Will Break Traditional Patient Accounting Systems

The Affordable Care Act includes many healthcare regulations unrelated to the distribution of insurance and expanding Medicaid. One important part of this legislation allows the federal government to explore new payment methodologies that they believe more accurately compensate providers for their services.  For acute care facilities, the term used for these new payment models is “Value-Based” payments where data previously considered to be unrelated to the billed services is used to determine the compensation for providers.

For hospitals providing services covered by this model, post discharge data is used to determine the outcome of the service.  This outcome will then have an impact on payments for these services.  In this new model, discharging a patient is no longer the “end point” of a billed service.  The service is expanded to include post discharge services and results.  This is a revolutionary concept and as it applied to other services, it will have major impact on the hospital industry in many ways that are both intended and unintended by this model.  Regardless of your point of view regarding the fairness of this payment model for this service and others like it, there will be problems with existing patient accounting systems in dealing with this new reimbursement model.

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Drones and Healthcare IT

It has been a month since my last post.  I normally don’t take so long, but sometimes life takes over and you don’t always have the free time to get your thoughts down on virtual paper.  Although my writing has been lax, I have been reading quite a bit lately.  Now it’s time to write again.

Around this time of year, we see the obligatory bests and worst lists of the ending year.  Like most people, when I read these lists I often think of what is missing that makes these lists incomplete or rankings that seem irrational or unjust.  There were several examples of these I saw regarding healthcare IT that examined the past year and what is coming in 2016.

Instead of discussing a list, I would like to point out a single completed objective that all of us should reflect on as we evaluate 2015 and look toward the future adoption of new technology in healthcare.  During late 2015, we converted from the ICD9 to ICD10 diagnosis code set.  This was over 90 days ago and the expected major disruptions associated with this change have never materialized.  Like Y2K and Obamacare, we have once again proven that healthcare is an industry that can absorb change and adapt to new procedures.  We have demonstrated again that we normally overestimate the negative impact of change and our ability to cope.

 

Drones and Healthcare IT

 

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The Double Standard for Healthcare Data

Healthcare providers collect an extensive amount of data regarding their patient’s medical history. Most providers understand the importance of maintaining accurate and complete health records. Collectively, this data tells a story of the medical history of the patient and can provide insight into new conditions or symptoms that might develop in the future. If you can combine the data from many patients into a database and examine it, new trends can be identified that can lead to new treatments, more efficient healthcare delivery, and better outcomes.

Provider organizations understand the value of this data. They would not think of discarding the medical record after a patient encounter or transferring the only existing copy of this data to a third party for processing, paying for a copy of the data if it was ever needed in the future or losing the data entirely if the third party goes out of business.

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