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How Unused Medicare Data
Can Improve Patient Care


Modify the HIPAA Eligibility Transaction System (HETS) to allow access to all eligibility inquiries for ACO-assigned beneficiaries and to develop a proactive, real-time notification system for ACOs when beneficiary eligibility is requested.


Doctor’s offices, clinics, hospitals, surgery centers, and other providers ping the HIPAA Eligibility Transaction System (HETS) to check patients’ Medicare eligibility at each encounter. If the Centers for Medicare & Medicaid Services (CMS), which operates HETS, allows access to the system’s data, then Medicare providers would have real-time knowledge of beneficiaries’ visits to medical providers, including hospital admissions, emergency department visits, and specialist encounters.

NAACOS developed, with the assistance of technical experts, an outline for an ACO Inquiry Notification System. The system, operated by a registered third party, would serve as a secure, point-of-service notification system. Leveraging real-time data feeds from HETS, the notification system would alert ACOs when one of their assigned patients may be seeking care or receiving services outside their ACO. This would limit customization and provide a simplified, user-driven approach to extract data from the current HETS system. Alternatively, CMS could allow Medicare ACOs the ability to securely access the system independently and monitor for their patients.


CMS has proposed to require hospitals send electronic notifications of patients’ admission, discharge, or transfer to their facility or another community provider. NAACOS supported the proposal and still believes that regulation should be finalized. But it wouldn’t include important notifications around emergency department visits, as one example. Allowing access to HETS data as a supplement to ADT alerts would provide information on all patient visits and place the onus on ACOs to track the whereabouts of their patients.


  The success of the ACO program is largely dependent on timely transfer of patient information and coordination of care.

Since Medicare patients have the right to seek care from any provider who accepts Medicare, it can be challenging for the ACOs to monitor services received by their assigned patients, particularly at the time of service.

Leveraging data feeds from the HIPAA Eligibility Transaction System (HETS), ACOs can tell when one of their member patients may be seeking or receiving services.

ACOs could intervene, for example, when a patient of theirs visits the emergency department, to offer the care coordination tools they’re designed to offer, making sure patients receive the right care, in the right setting, at the right time.