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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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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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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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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