New NPI Verification Process for Eligibility Inquiries Set to Begin

After years of delays, the process for verifying eligibility will soon change for healthcare providers throughout the country. CMS is migrating hospital, home healthcare, hospice and skilled nursing (Part A) eligibility inquiries from the Common Working File system (CWF) to the HIPAA Eligibility Transaction System (HETS) in the fall. After that time, providers will no longer be able to access CWF to verify eligibility. The transition will not impact access to the CWF for claims management.

Healthcare providers who want to verify Part A Medicare eligibility benefits will be required to use a National Provider Identifier (NPI) that is registered in the Medicare Provider Enrollment and Chain/Ownership System (PECOS) database. As part of the eligibility process, these eligibility applications will verify that the NPI used on the inquiry is present in the Medicare PECOS database.

What to expect

Whether you work in an acute or post-acute setting, the change means that inquiries made with NPIs NOT present in the Medicare PECOS database will fail to return Medicare eligibility data. To avoid verification disruption, it’s critical that you review the PECOS status for any NPIs currently used by your organization. If your NPIs are not currently registered with PECOS, update that information accordingly. Additional information on PECOS and how to register your NPI can be found here.

What if your organization uses HETS, or uses both HETS and CWF for eligibility verification? If you’re already using HETS, there’s nothing you need to do. If you’re currently using both systems, you should start using HETS exclusively.

How we got here

CMS first signaled plans to discontinue eligibility checks through CWF in December 2012, announcing that HETS would be the single source for this data. After receiving feedback about – and later resolving – the differences in data returned from the two systems and the one-year limit to HETS historical searches, CMS is now moving forward with the transition to one system.

ABILITY® has you covered

As was the case in previous CMS transitions, ABILITY is well prepared to make sure healthcare providers experience no disruption.

For ABILITY EASE® Medicare, ABILITY CHOICE® Medicare Eligibility and ABILITY COMPLETE® customers, the transition is a non-event. Providers can continue to verify eligibility in CWF until CMS requires the move to HETS. From there, ABILITY will manage the transition to HETS to ensure a seamless transition for the customer. It’s one of the many ways ABILITY helps simplify complexity for its customers.

eligibility verification

3 Ways to Make Your Eligibility Verification Process More Efficient

Eligibility verification is the first step in the revenue cycle – and arguably, the most important. Without an efficient verification process, it’s hard to communicate with payers and determine payer/patient payment responsibilities. These challenges can increase the number of mistakes made during claims submissions. They may also add time to your average A/R days or lower the revenue you’re able to capture each month.

If you’re familiar with the costs of patient eligibility challenges, try a different verification approach. Here are three ways you can increase eligibility verification efficiency.

1. Take advantage of real-time eligibility verification opportunities

Verifying patient eligibility via individual payer portals or over the phone is not ideal. These processes are extremely time-consuming. They delay patient access to treatment and often cause stress for front-of-house staff.

A real-time verification process, available through a single eligibility portal, is much more efficient. It simplifies communication with payers and provides quick eligibility answers, meaning your team can verify coverage in a matter of seconds, not hours or days.

With the right tool, you can enjoy this fast, highly efficient workflow to communicate with Medicare, Medicaid and private payers.

2. Save time with saved patient data  

Real-time verification is just one of the many workflow benefits that an eligibility portal like ABILITY COMPLETE® can provide. Additional functions may include storage of eligibility transaction history and the ability to resend prior eligibility requests.

Having access to this data offers significant time-saving opportunities. It gives your team all the information they need to quickly verify patient eligibility every single time a patient comes in. This replaces the slow, tedious task of asking patients to fill out forms and having staff manually input their information. It results in increased patient satisfaction and decreases the likelihood of sending claims with inaccurate information.

3. Educate patients and collect payments before treatment

To achieve a high level of efficiency throughout the revenue cycle, engage patients early on. Educate them about their coverage and their payment responsibilities. Break down the costs of treatment for both long-term and one-time services, and collect each payment at the time of service.

Providing patients with an understanding of their payment responsibilities up front helps your business avoid possible loss of payments. It reduces the risk of inadequate benefit challenges after treatment has started, and it increases the likelihood that a patient completes their long-term care plan.

Innovative processes combined with attentive patient care can transform your RCM performance. In terms of eligibility verification alone, the best way to improve efficiency is to focus on working faster while producing more accurate results.