Medicare eligibility system: CMS turns out lights on new applications

Sunday, October 21, 2007

WASHINGTON - Providers who want to start checking patient eligibility using CMS's online system are out of luck.

The agency announced Oct. 12 that it has enacted a "temporary moratorium" on new applications for its Medicare HIPAA Eligibility Transaction System (HETS) 270/271. Those who already have "submitter ID numbers" can continue using the system.

CMS's timing couldn't have been worse, said Edward Kutt, president of Diabco, a software vendor.

"We just got back from Medtrade with the names of more than 100 providers who are interested in our product," he said. "We also have a lot of contracts pending. Those providers are stuck, too."

Vendors like Diabco, Brightree and Noble House pointed out the moratorium only affects eligibility software and not other product offerings.

CMS has enacted a moratorium before. Last year, the agency temporarily closed the door on new applications to address technical issues with the system. That was understandable, industry sources said, because, at the time, the system was still fairly new.

But CMS failed to state a specific reason for the moratorium this time. The only hint: In a notice, the agency stated it was conducting an "intense evaluation."

Industry sources believe CMS could still be tweaking the system due to increasing demand.

"They're still investing significant time and energy to improve it," said Dave Cormack, CEO of Brightree, a software vendor. "They want to make it the portal of choice for eligibility information."

(Providers can also call a toll free number to get eligibility information, but it can take up to 10 minutes per patient.)

Some industry sources fear CMS may have ulterior motives.

"It may have something to do with some providers running eligibility multiple times for the same patient, which our clients don't do often," said Richard Basch, director of marketing and sales for Noble House, a software vendor. "Originally, there was a formula for checking the eligibility of a patient only so many times. If a provider was over that threshold, then CMS could start to take action. I'm not sure this has anything to do with that."

CMS also failed to state how long it would keep the moratorium in place.

"It would have been nice if they had given us some warning," Kutt said. "It would be like the power company turning off your lights to evaluate new light bulbs, and they don't tell you when they'll be done. In the meantime, you have no electricity."