GAO Report: Medicare Transaction System HETS Performance Improves

Two years ago the performance of Medicare’s online eligibility system that providers across the country use to determine eligibility and benefits was dismal, but a U.S. Government Accounting Office investigation released last week found most of the issues have been corrected and there was reason for optimism in the years ahead.

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Centers for Medicare & Medicaid Services’ (CMS) HIPAA Eligibility Transaction System (HETS) is the online tool from which Medicare providers obtain eligibility data for patients that is used to file Medicare claims, determine beneficiary liability, or determine eligibility for specific services. Most providers query HETS through private clearinghouses which employ the HETS 270/271 system to request eligibility files over a secure connection.

HETS conducts on average 2 million transactions each day. Two years ago  2 out of every 3 queries made into the HETS system failed to complete within the targeted response times. By June of this year, 99.9 percent of all queries was being completed within the optimal 3 seconds.

According to the U.S. Department of Health and Human Services, its efforts to correct operational problems and improve the reliability of HETS has been a “success,” but the GAO was more conservative in its appraisal, writing that CMS had taken steps to correct the issues.

The GAO turned it focus toward HETS in September 2011 at the request of Republican senators Orrin Hatch (Utah), Tom Coburn (Oklahoma), and Richard Burr (North Carolina). (link to Modern Healthcare story contains link to the letter) http://www.modernhealthcare.com/article/20110921/NEWS/309219940. The senators reported that they had received numerous complaints from providers and beneficiaries “over unusually long wait times while trying to affirm eligibility via HETS, to providers not being able to get through on the secondary channel of 1-800-MEDICARE.”

The GAO, in its investigation, found that response times had been poor from January 2010 to October 2010, when only 1 in 3 attempts to query HETS resulted in a response in less than 3 seconds, and a third of queries took longer than 10 seconds or were never completed at all.

According to the GAO, CMS managed in a large part to correct the issues by beefing up its hardware and software landscape so that by March 2011 the response time on 96.3 percent of queries fell under the response target of 3 seconds. Those improvements hit a snag in July and August, when at times 5 percent of all queries experienced poor response times. Those performance issues corresponded to the action of the senators who called for the GAO investigation.

Every July and August, at least according to GAO data, the volume of HETS queries increased by 10 to 20 percent, and in 2010 and 2011 performance of the system degraded. The GAO report only provided data through June of 2012. insidePatientFinance spoke with one of the four network partners for HETS that provide connectivity for the more than 100 Medicare data clearing houses. The network vendor reported no substantial connection issues with HETS in July and August of this year, except during scheduled maintenance systems.