Computer Software Update

• By Michael Gerardi, Louis Feuer
• Jun 01, 2006

In the latter half of last year, the Centers for Medicare and Medicaid Services (CMS) reactivated the online patient eligibility project once again. My original exposure to the eligibility project started back in the spring of 2003. At that time, there appeared to be a lack of coordination between the DMERCs as to how the CMS data was to be disseminated across each of the four regions. It appeared that each DMERC would have its own ability to process eligibility requests. My initial development was through DMERC Region B, AdminiStar. Administar's software team had the expertise and knowledge to make this project function without much of the headaches and problems normally associated with a project of this magnitude.

Standardization has benefited not only software vendors, but also the entire health care community.

The specifications at that time required that a request for eligibility information be presented initially to the local DMERC, and then on to the other regions in an attempt to locate the proper information for that beneficiary. After many trials and tribulations, we were finally successful in retrieving real-time patient eligibility information. However, as soon as we were ready to move into production with our new management tool, CMS slammed the brakes on the projects, citing security issues as the main culprit. This abrupt halt to an exciting project was quite frustrating and we were beginning to realize the potential of patient eligibility.

Fast Forward Three Years

With the implementation of HIPAA and the format of medical information from claims (ANSI-837), remittance response (ANSI-835), claim status (ANSI-276/277) and patient eligibility (ANSI-270/271), information has now been totally standardized. Standardization has benefited not only software vendors, but also the entire health care community.

In the summer of 2005, CMS announced the resurrection of the ANSI 270/271 patient eligibility project. After some fine-tuning and redesign of their initial specifications, CMS resolved some troubling issues and streamlined the eligibility process. In no time at all, I was able to dust off our aging programs from three years prior and establish connectivity to CMS once again. Only this time, the convoluted method of finding a patient had been neatly redesigned. Now a single database of beneficiary information is maintained for the entire country. No more headaches of searching for a patient across a slew of databases.

Patient Eligibility Benefits

Currently, CMS is maintaining at least two distinct databases for patient eligibility information. The original system is maintained for their Automated Voice Response Unit and CSI/Passport systems. While this system has been in place for a while, it is rather tedious and time-consuming to process numerous patients all at once. The new online eligibility database is maintained on a daily basis and contains the most current data available. As with any industry maintaining multiple versions of the same data, there will always be confusion as to which database is most current. This new system allows for both real-time and batch submission of queries. Designed to provide a response within seconds of a request, the system allows CMS to process thousands of eligibility requests per hour.

The usefulness of patient eligibility has multiple applications. Initially, health care providers verify that a patient has coverage for the services being rendered. Once patient coverage has been established, the provider then evaluates any deductible balances that they may have. Using this information, the provider then has a better understanding on how to effectively manage this patient.

Health care providers that work within a mail-order or other high-volume environments, such as diabetic supplies, enteral nutrition, etc., rely heavily upon the eligibility information to confirm coverage and deductible status at the time of the services being rendered.

Since the implementation of our patient eligibility system late last year, we have experienced a tremendous reception to the integration into our suite of software products.

Back in the early 1990's, electronic remittance was just on the horizon. Now, patient eligibility is here to stay. With electronic remittance, most software products were not capable of integrating the payment data directly into their application. Today most, if not all, software vendors have that capability. While that integration took years to catch on, don't be surprised to see patient eligibility (ANSI 270/271) catch on overnight.

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Patient Eligibility Benefits:

1. Retrieve Real-Time Eligibility via CMS within seconds
2. Verify Medicare Part A and Part B Coverage
3. Determine Annual Deductible Balances
4. Identify Primary Payor other than Medicare (HMO)
5. Present Hospice Information
6. Verify Patient's Name and Address on file with CMS

This article originally appeared in the June 2006 issue of HME Business.