Part B Insider (Multispecialty) Coding Alert

Published on Wed Jul 06, 2005 PDF

Medicare gives up on name/Id edit-for now

Pressure from thousands of providers has led the Centers for Medicare & Medicaid Services to reverse an edit that was causing  massive denials.

Since CMS instituted an edit requiring providers to match Medicare beneficiaries' names and Medicare ID numbers exactly, some providers have had as many as 30 percent of their claims denied. But now CMS officials say the edit is being deleted for now.

Officials say they decided the edit was "too restrictive," perhaps because of the excessive number of denials. CMS hasn't announced the change publicly, except to revoke a Medlearn Matters article about the requirement (SE0516). But you can't kiss the edit goodbye forever - the agency is reworking it, and plans to reinstate a revised version at some point in the future.

But for now, providers and billing experts rejoice at the disappearance of the troublesome edit. "This one issue has created more aggravation and denied claims to Medicare than any other reason recently," says Susan Callaway, an independent coding auditor and trainer in North Augusta, SC.

"Medicare has obviously realized that the requirement created more work for them as well," Callaway concludes.

CMS might have expected that problems would subside as physicians became accustomed to the new requirement. In fact, "claims rejections have been increasing, but not to a point where it was critically impairing financial status of the physician," notes Michelle Logsdon, with Falcon Practice Management in Bayville, NJ.

"The Medicare program dramatically underestimated the impact or side effects of this change," says consultant Bob Burleigh with Brandywine Healthcare Services in Malvern, PA.

Slightest Mistake Could Be Fatal

The edit meant denials "anytime a human error is there in typing or spelling of a name, even missing a middle initial," Callaway complains.

"There are too many points to match for the claim to get paid," says Logsdon. "For a physician's office, it is easier to get a copy of the Medicare Card and ensure that the information matches exactly. But my surgeons, who get their information from hospital face sheets, don't have that luxury."

Sometimes a patient will be named Margaret but the physician office will bill using the name Maggie, says Logsdon.

"The problem that we run into a lot of times out of here is somebody doesn't like their first name so they use their middle name and it doesn't match up," says Brenda Dennis, team leader with Peninsula Cardiology Associates in Salisbury, MD.

The name/ID requirement was symptomatic of CMS officials' lack of understanding of how physicians and other providers exchange information, says Burleigh. Even a primary care practice may not look at a patient's Medicare card every time he or she comes in, and many patients probably keep their Medicare cards safely in a drawer at home to guard against identity theft. For long-standing patients, the practice may not have seen the Medicare card in years.

And if a patient comes into the emergency room, all sorts of providers may treat him without ever meeting him or seeing his Medicare card. The emergency physician, radiologist, pathologist and other physicians will be at the mercy of the hospital's possibly faulty information. "They are now the downstream inheritors of the same problem," says Burleigh.

But billing experts agree that some means of verifying patients' identities could be a valuable anti-fraud mechanism. Forcing providers to use patients' legal names is "a positive thing, and it turned out to be a little hassle," says Dennis. "It just makes things a lot easier in the long run," if physicians have patients' full legal names.

"There should be some type  of edit that cuts down on  fraudulent claims," says Logsdon. She suggests that CMS should reinstate the edit for date of birth, Social Security Number and Medicare number, but not name. "The name should be a secondary issue," she says.

But Callaway is more pessimistic. "There is no better edit mechanism," she says. "The edit is not practical, because of human error."