In this episode, Jon Besler, BESLER Consulting’s President & CEO, explains what the HIPAA Eligibility Transaction System (HETS) is, why it’s replacing the Common Working File (CWF), and the unintended consequences that could cost your hospital revenue.
HETS is essentially Medicare’s replacement for the CWF as it moves towards deploying a HIPAA compliant database.
Jon notes that one of the most significant changes regarding this transition is that retrospective access to claims data through HETS is proposed to be 12 months. Currently, in the CWF, providers can look back four years to make claim adjustments.
Impacts of this change include:
- The inability of providers to review claims previously audited by RACs
- Limiting retrospective Transfer DRG billing adjustments
- Inability to verify the status and start date of beneficiaries’ eligibility relative to claims used to calculate penalties for the Hospital Readmissions Reduction Program (HRRP) or the Hospital-Acquired Condition Program (HACRP).
Any hospital using the Common Working File for claims review will be affected by the change to HETS.
CMS has not yet set a mandatory date for transition to HETS. However, CMS has said that upon a 90-day notice to the provider community, they can eliminate access to the Common Working File and fully implement the HETS system. At this time, no announcement has been made.
Hospitals may not be aware of this issue because CMS published this information through a very informal process called a release summary. These summaries are essentially outside of the traditional rule-making process which would allow providers to comment and discuss proposed changes with CMS.
While the movement towards a more HIPAA-compliant system is a favorable development, the proposed look back period for hospitals is concerning.
BESLER Consulting has worked with the New Jersey state hospital association other state hospital associations to help shepherd a meeting with CMS to make them aware of the concerns around the look back period and some of the unintended consequences accompanied by this proposed change.