CMS gets good report card on improving its Medicare eligibility IT

The Government Accountability Office (GAO) has given the Centers for Medicare & Medicaid Services (CMS) the nod for effectively upgrading its healthcare IT system used to verify eligible Medicare beneficiaries.

In a report released on Monday, the GAO revealed findings of its most recent review of the real-time CMS eligibility data processing system, known as the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Eligibility Transaction System (HETS).

According to the GAO, 244 entities were using HETS in 2012, including about 130 providers, 104 clearinghouses that provide data exchange services to about 400,000 health care providers, and 10 Medicare contractors that help CMS process claims for services. From January through June 2012, HETS processed each month an average of 1.7 million to 2.2 million queries per day with most of the queries submitted between the hours of 8:00 a.m. and 4:00 p.m. eastern time.

[See also: GAO finds RAC project falling short.]

Users of the system interviewed by GAO said they were satisfied with the system, which had not been up to snuff over the past few years. According to GAO, CMS has resolved the operational issues they had in 2010 and 2011. System performance reports for the first six months of 2012 showed that the average response time per transaction was less than three seconds. Users told GAO that the upgraded CMS system now provides more complete information and reliable service than other systems that they use to verify eligibility with commercial health insurers.

CMS took steps to ensure users remain satisfied with the system’s performance, including notifying users in advance of system downtime, providing help desk support, and monitoring contractors’ performance, according to GAO. The agency had also planned several technical improvements intended to increase HETS’ capacity to process a growing number of transactions, which the agency projects to increase at a rate of about 40 percent each year. These plans include a redesign of the system and migration to a new database environment that is scalable to accommodate the projected increase in transaction volume.

According to HETS program officials, near-term plans also include the implementation of tools to enable proactive monitoring of system components and additional services intended to enhance production capacity until the planned redesign of the system is complete.

[See also: GAO focused on $2.3B EHR incentives for 2011.]

To help protect the privacy of beneficiary eligibility data provided by HETS, CMS has established policies, processes, and procedures that are intended to address principals reflected by the HIPAA Privacy Rule, according to GAO’s study. For example, in its efforts to ensure proper uses and disclosures of the data, CMS documented in user agreements the authorized and unauthorized purposes for requesting Medicare beneficiary eligibility data. Additionally, the agency conducted privacy impact and risk assessments of HETS as required by the E-Government Act of 2002.