Medicare Transaction System: platform for change - Medicare Payment Systems: Moving Toward the Future

Health Care Financing Review, Winter, 1994 by Mary E. Warren, Karen E. Jackson, Eric L. Veiel

The MTS will improve services to beneficiaries and providers by supporting a single point of contact for information on entitlement, eligibility, benefits, payment decisions, and claims status. A beneficiary or provider will be able to call any Medicare customer service organization (intermediary, carrier) and receive answers to basic questions about any claim. The MTS will also greatly enhance the coordination of supplemental insurance benefits by automatically sending claims data to other insurers for their share of payment without additional beneficiary and/or provider involvement.

Administrative efficiency will be achieved by having only one system. A single system will allow changes to be made faster, more easily, and with greater accuracy and uniformity, and will eliminate redundancies in data needs, files, and processing.

The MTS will provide an improved ability to detect fraud and abuse; to detect suspicious billing patterns and aberrancies; and to bring about early trend detection, facilitating HCFA's management of program expenditures. MTS will simplify information and data flow and will increase standardization and uniformity of operations.

FEATURES

HCFA looks forward to achieving several goals and objectives by incorporating key features within the system, such as its integrated claims processing capability. MTS will facilitate the administration of technological upgrades to the system. Changes resulting from new legislation will all be controlled by HCFA and implemented through the MTS while data and system integrity are ensured. In the current claims processing environment, any global modifications must be implemented individually by the various systems and can result in inconsistent changes and thus inconsistent Medicare benefit determinations. Such problems will be avoided upon completion of the MTS.

Another key feature is that MTS represents a significant step toward greater automation in the Medicare claims process. Upon implementation, most Medicare beneficiary billing history, eligibility, and provider data will be available to Medicare providers and suppliers electronically with access determined and controlled in accordance with Federal privacy and confidentiality requirements. Electronic access to this data will also enable the speedy and accurate handling of beneficiary problems, provider questions, and claims status determinations by carriers and intermediaries.

Yet another key feature is that the MTS will employ open systems architecture. This will allow for hardware independence, meaning the MTS will not be dependent upon any one computer manufacturer's hardware. Since the MTS will be Government-controlled and contractor-operated, no changes can be made to the system unless approved by HCFA, thus ensuring standardization. Although there will be only one version of the system, it will stir accommodate local variation in medical review policies (Health Care Financing Administration, 1992b).

HOW WILL IT WORK?

The MTS will consolidate Medicare claims processing by replacing the standard systems and the CWF and integrating Part A and Part B claims processing. The structure envisioned for an MTS environment requires local contractors (carriers and intermediaries) to continue to provide customer service functions to Medicare beneficiaries and providers. The MTS operating sites (the number of which will be determined at a later date) will carry out the automated claims processing functions.