Acute Care Hospitals Should Receive Access to HETS Eligibility Data Specifically for “Good Cause” Claim Re-Openings

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BESLER Consulting publishes issue brief about the implications of the elimination of the Common Working File for Acute Care Hospitals

BESLER Consulting has published an issue brief that explores the implications of the elimination of the Common Working File (CWF) for Acute Care Hospitals.

Currently, Medicare regulations allow providers to issue a “Good Cause” claim reopening outside of timely filing in situations where “new and material evidence” and “clerical errors” occur. When CMS completes its transition to the HIPAA Eligibility Transaction System (HETS), the Common Working File will be eliminated. Since providers will not have access to the CWF to confirm and review Medicare eligibility data prior to the issuance of the claim re-opening, it will be impossible to access the information used to validate whether a re-opening is warranted.

CMS’ initial plan was to give providers HETS access to beneficiary eligibility information going back 27 months. This is much less than what is available today and significantly less than the four-year time period during which hospitals are allowed to reopen claims. CMS then revised their plan and recently announced that it will be reducing access to HETS eligibility data from the original intended 27 months to 12 months.

Claim re-openings are the hospitals’ only avenue to ensure proper reimbursement outside of timely filing, and the elimination of the CWF without a viable alternative effectively closes the door on the hospitals’ ability to pursue claim re-openings under the regulations. CMS allows Recovery Audit Contractors (RACs) to retrieve and review this information for purposes of their investigations, however, under this proposed change, providers would not be afforded the same timeframe.

“It is BESLER’s opinion that CMS should offer an exception for access to HETS eligibility data specifically for ‘Good Cause’ claim re-openings,” said Jonathan Besler, President and CEO of BESLER Consulting. “This proposed change will deprive providers of their right to reopen and validate claims in accordance with Medicare regulations. CMS intends to provide up to twenty-seven months to access eligibility data for DSH reporting purposes. We strongly believe that, at a minimum, a similar accommodation should be made so that hospitals can submit re-openings in accordance with the existing regulations and be paid appropriately for care furnished to their Medicare patients.”

To read the full issue brief, visit http://www.besler.com/issue-brief-common-working-file/

About BESLER Consulting

For over 26 years, BESLER has helped hospitals enhance and protect their Medicare revenue. BESLER’s deep domain experience in revenue cycle, reimbursement, compliance and software development has resulted in more than $2 billion of additional revenue for our clients. For more information, visit http://www.besler.com.

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Michael Passanante
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