CMS must use new technology to comply with looming MACRA requirements

This April the Centers for Medicare and Medicaid Services (CMS) must meet the deadline looming to implement the New Medicare Card initiative under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).

As CMS undertakes this herculean task – arguably the biggest change the agency has ever had to implement – it must deploy the right technology to guard against the many potential errors in patient identification.

This is especially important in light of the dramatic scope of change required by MACRA. CMS is not just tasked with issuing new Medicare cards to every single beneficiary – MACRA also includes a requirement that all federal and private health information systems be ready to process newly-generated Medicare identification numbers in 2018. This provision, previously called the Social Security Number Removal Initiative, presents an unprecedented logistical and administrative challenge to CMS.

The MACRA-imposed changes are larger than anything the system has experienced recently – and possibly ever in its history. This is bigger than the 2006 implementation of the Medicare Part D prescription drug benefit, when approximately 23 million Medicare beneficiaries changed or obtained new drug coverage. It also outsizes the roughly 17 million individuals who gained coverage through the individual market for Medicaid in 2014. The effects of both events pale in comparison to the impact that will be felt by the 60 million active Medicare beneficiaries who will be assigned a new Medicare number. Consider the following:

The New Medicare Card initiative will replace Social Security Numbers with Medicare Beneficiary Identifiers (MBIs), which will include 11 characters, both numeric and alphabetic. The MBIs will be unique, non-intelligent (i.e., not related to patient information), and randomly generated. As an example, CMS provides 1EG4-TE5-MK73.
CMS will then need to replace Medicare cards for 150 million beneficiaries (90 million of whom are deceased).
To use these new MBIs, CMS will have to replace 75 legacy information systems that are used to process claims, both within CMS and for its contractors.
Hundreds of thousands of private systems that handle claims will need to be updated.
For perspective, consider that the New Medicare Card initiative will roughly double the typical number of insurance identification changes providers experience annually. In a given year, approximately 20-30 percent of insured Americans change health plans, meaning providers must update insurance information for roughly 58-87 million Americans. In addition to this already massive number, providers will now have to process the 60 million new MBIs.

Further implications

Changes in personally identifying information, such as the Medicare beneficiary number, increase the likelihood of provider errors. This is especially true in the process of patient identification – the means of accurately identifying patients and matching them to their intended services, treatment, and unique individual medical records. Patient identification errors are so prevalent that the Joint Commission listed accurate patient identification among the top priorities in its National Patient Safety Goals first issued in 2003.

MACRA and the potential for misidentification

The complication of the New Medicare Card initiative could significantly increase the number of patients misidentified during medical records searches. Consider these three scenarios:

As a Medicare beneficiary registers with a provider, she presents her Medicare card and another form of identification. The registrar queries the electronic medical record using the new Medicare identification number, doesn’t find a record, and mistakenly assumes the patient is new. The registrar then creates a new, duplicate, and incomplete record.

The in-take staff correctly matches a patient to his existing medical record, but makes a data entry error when updating the new MBI. The error isn’t caught in a timely manner, causing claims processing disruption for the provider.

When in-take staff can’t find a patient using the new Medicare identifier, they select the wrong patient record at registration, and clinical staff continue to use that incorrect record throughout the encounter (an overlaid record). Two patients’ records are now compromised; the wrong patient’s insurance is billed for services provided, and providers incur costs both to resubmit the claim and to correct the medical record that was overlaid with another patient’s information.

Clearly, patient identification errors have both quality and financial consequences. Patient misidentification can result in temporary or permanent harm, or even death. Beyond the risks for clinical error, healthcare providers lose significant net patient revenue each year due to patient identification-related claims denials.

In addition to revenue loss from denied claims, providers also face internal costs of fixing duplicate and overlaid records. Estimates indicate that approximately 8-12 percent of all hospital medical records are duplicates, and that fixing them can cost up to $100 per record. Overlaid medical records are even more complex and costly to fix, at thousands of dollars per record.

So is patient misidentification a big deal? It is. And with the new Medicare Card initiative roughly doubling the number of Americans with new insurance identifiers, it’s worth planning for this transition before it creates real problems.

Technology exists to manage this unwieldy change-over. CMS should make significant investments in new tools and infrastructure: care management, information technology, data analytics, workforce redevelopment, care teams, ambulatory practices, and so much more. Biometric tools should also be part of this suite of innovations. Biometric patient identification creates a single, unique identifier for every patient, which may be used across multiple records systems and clinical sites.

CMS certainly has a monumental job ahead, and with the April deadline looming, time is of the essence. As CMS finalizes its strategy to align with MACRA requirements and implement wide-scale changes, it would do well to use the existing technology tools that are proven to decrease patient identification errors, or eliminate them altogether.

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