How to Protect Revenue While Protecting Patients’ Identity
For accredited teaching hospitals, Indirect Medical Education and Graduate Medical Education (IME and GME) are important means of supplemental reimbursement to compensate for the costs of training medical residents and interns. While most providers have developed strong internal processes to ensure all revenue is captured, there is still potential for leakage if the proper information is not captured upfront. In our experience, providers capture between 92% – 99% of claims that should be shadow billed. While this success rate appears strong on the surface, even missing only 1% of these claims can result in the loss of over $1,000,000 annually.
In this post, we will focus on the transition period from the current Medicare Health Insurance Claim Number (HICN) to the Medicare Beneficiary Identifier (MBI), which will end on December 31, 2019. This transition represents a significant impact to providers and requires changes to transactions such as billing, eligibility, and claims status. In addition, this change will have an impact on how providers research and submit shadow bills. We will explain key challenges and provide recommendations to limit your exposure and potential revenue leakage.
Hospitals that have an accredited teaching program are entitled to reimbursement in the form of supplemental payments related to the medical education costs of treating inpatient Medicare patients. This reimbursement is provided via IME and GME payments and claims are also included in the Medicare fraction of the Disproportionate Share Hospital (DSH) calculation via beneficiary days. For Medicare fee-for-service claims, these payments and patient days are processed and reported automatically. However, for Medicare Advantage claims, an information-only claim, also known as “shadow bill,” must be submitted by the provider to Medicare.
When submitting these “shadow bills” for Medicare Advantage patients, a provider is heavily reliant on the patient’s HICN, which is not the same as their Medicare Advantage plan number, to properly route the claim to Medicare. Currently, when patients do not present with this information upfront, providers often rely on the patient’s social security number (SSN) to research the proper HICN via the Common Working File.
In 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) included legislation mandating that CMS replace the current SSN based HICN with new MBI for all Medicare beneficiaries by April 2019. The main goal of the legislation was to protect Medicare beneficiaries from fraudulent use of their SSN, which could lead to identity theft and illegal use of Medicare benefits. Between April 2018 and April 2019, new Medicare cards with unique MBI numbers were mailed to all Medicare beneficiaries. As such, providers should have already seen an influx of Medicare patients presenting with this new information. While the change represents a significant step for protecting beneficiaries, it also represents a significant challenge for providers.
Unlike ICD-10, the transition from the HICN to the MBI should not have a significant impact on systems in terms of field length and alphanumeric characters, as the MBI is structurally similar to the HICN. While the MBI will be clearly different than the HICN, MBIs should fit on forms the same way HICNs do. The challenges, instead, are in obtaining the correct information and ensuring strong processes are in place to utilize MBIs by January 1, 2020. Key challenges include:
Patient Awareness, Education, and Cooperation
Payers and providers will not be provided with the patient’s MBI information. As such, providers must rely on patients to provide this information at the time of registration. Exasperating provider challenges, CMS is coaching patients not to share their SSN.
While all Medicare beneficiaries should have been mailed a new card at this point, they may not understand why they received a new card or what action to take. Medicare Advantage beneficiaries may require additional education, as their Medicare Advantage programs have their own unique cards, and they may not understand the difference between the two or the importance of having both. If a Medicare Advantage patient only presents with their Medicare Advantage card, it may be difficult to obtain the patient’s new MBI.
Increased Reliance on Patient Access
As patients and providers become accustomed to utilizing the new MBI numbers, a heavy burden will be placed on patient access staff, as they are the first line of defense in obtaining and documenting this information. Team members responsible for patient registration and insurance verification must be prepared to devote additional time to educating patients and employing new methods of research to identify and record accurate beneficiary information.
Provider System Upgrades
While the MBI is structurally similar to the HICN, during the transition period there could be a need to have both numbers readily available. Currently, a patient’s MBI is provided on the remittance advice even when the HICN is used. This is located in the same place as the “changed HICN”: 835 Loop 2100, Segment NM1 (Corrected Patient/Insured Name), Field NM109 (Identification Code). Billing and claims filing software should already be undated to accommodate this change.
Being ready for the transition and having strong internal processes and education in place are key to success in the change from the HICN to the MBI. Capturing accurate and complete insurance information upfront can help prevent revenue leakage and reduce denials. In the case of Medicare Advantage patients, having this information also allows providers to properly submit shadow bills to capture additional reimbursement in the form of IME and GME payments. Below are some of the key strategies for how to stay ahead of the curve:
- Ask your Medicare patients for the necessary information upfront. During registration, make sure that you are obtaining all relevant insurance information, inclusive of the MBI number, so that you can track this at inception.
- Sign up for and get comfortable with your Medicare Administrative Contractor’s (MAC) secure MBI look-up tool. While ideally patients will provide this to you at registration, anticipate that some patients will not have this information. In these instances, you can utilize your MAC’s secure look-up tool to identify the MBI. This will replace prior processes which allowed you to look up this information via the Common Working File, which, starting in January 2020, will return an error if you input a HICN. In order to look up a patient’s MBI in the new look-up tool, you will need to input the patient’s name, date of birth, and SSN. If the patient refuses to provide their SSN or if you do not have this information on file, you can ask the patient to log onto mymedicare.gov to obtain their MBI. Please note, attempting to use the patient’s prior HICN on file to look-up their new MBI will be a challenge, as the HICN utilizes the SSN of the primary wage earner, which may not be the patient. Finally, if the look-up tool returns a last name matching error and the beneficiary last name includes a suffix such as Jr., Sr., or III, try searching with and without the suffix as part of the last name.
- Provide education for patient access staff and ensure coverage is adequate to compensate for additional time needed for patient registration. Ensure registration and insurance verification team members understand the importance of obtaining the MBI when the patient is present and the downstream implications if this is not captured. Ensure familiarity with MAC secure look-up tools and provide guidance and scripts for educating patients.
- Ensure that your systems are well equipped to accept and store the new MBI number. Build capabilities such that the MBI is automatically captured and recorded when provided on the remittance advice (835) during the transition period. Test claims with the MBI to ensure proper processing and payment. Coordinate with outpatient sites and any ambulatory and referral networks, as information could flow from these sites.
- Prepare for things to slip through the cracks. Internally, implement an edit or workqueue for cases where information could not be obtained upfront and train key staff members on how to obtain this information. Conduct an internal audit or leverage an external company to audit your IME/GME billing process to ensure you are capturing all of your potential IME/GME reimbursement. Cloudmed has experts in IME/GME reimbursement and works with many teaching hospitals to recover lost revenue in this space.
Providers should ensure that they are communicating a clear plan of action and have a proactive approach to confirm that they are capturing all MBI information from beneficiaries from the start. Coordination across departments is crucial as this change will impact multiple years of information and processes that are currently dependent on the HIC number. In order to handle the transition to MBIs, organizations need to prepare themselves. By developing advanced strategies and leveraging an internal audit or an external vendor to conduct a secondary sweep of opportunities, providers will be able to navigate these changes efficiently.