The U.S. Centers for Medicare and Medicaid Services (CMS) Offices of Hearings and Inquiries handle a plethora of exceptions or issues facing Medicare beneficiaries, including managing and providing oversight to the identification and correction of data discrepancies in Medicare enrollment, direct and third-party billing, Medicare Advantage, and Part D transaction exceptions, screening complex casework for verification, and coordinating disposition, among many others. The problem could be anything from an error to a scam that could negatively impact the beneficiary’s current status.
The COVID-19 pandemic has exacerbated issues facing vulnerable populations, so CMS must take measures to protect Medicare beneficiaries. Any problem that jeopardizes the beneficiary’s benefits must be investigated and resolved, in some cases within 24 hours. For over eight years, HMS has supported CMS to resolve “exceptions” that interrupt beneficiaries’ ability to stay current with Medicare, explains HMS Project Director Gwendolyn Graves.
An exception is anything that negatively impacts a beneficiary’s account status. A few examples include:
- A Claimant Account Number or Beneficiary Identification Code might be missing from the file.
- A check might have insufficient information or more than one beneficiary listed.
- A check might contain name or dollar-amount discrepancies.
- A beneficiary’s Medicare number might have been compromised and needs to be reassigned.
- A Medicare account needs to be cross referenced to synchronize a record.
Those are just a few of the myriad challenges that kick checks and Medicare cards out of the processing stream for investigation and resolution. “We make sure payments are processed, beneficiaries’ information is specific, and their personally identifiable information (PII) is secure and accurate. Any time there is an issue with that, the work comes to us to fix it,” says Graves.
Many cases processed by HMS are called “lock box exceptions,” which is when a bank kicks back a premium payment and we have to determine why the payment did not go through. HMS has to do the research necessary to identify who the check belongs to and resolve any discrepancies or questions that caused the bank to refuse payment, which often entails directly reaching out to the bank and/or beneficiary.
The HMS team processes well over 100 Medicare Beneficiary Identifier (MBI) reassignments on a typical day for beneficiaries who feel that their MBI number has been compromised. But that number can balloon to a much higher number following a long weekend. The commitment to CMS is to reassign a new number within 24 hours. HMS is required to submit a monthly report of the previous month’s activities.
This essential work had to quickly be adapted to the restrictions created by the pandemic in 2020, so HMS created a new remote-work model that included instruction, coaching, and troubleshooting in order to keep everyone involved in the workflow healthy and safe — without slowing the exceptions resolution process down.
Responding to Scams
“One of the big things we do is help vulnerable individuals who have been scammed,” says Graves. “A lot of Medicare beneficiaries are being hit really hard with scam phone calls.” Scammers use all kinds of stories designed to trick beneficiaries into revealing their Medicare number. Once a scammer gets that number, they can wreak havoc on a beneficiary’s life through identity theft, including getting their hands on the beneficiary’s Medicare payments.
The HMS team sends out a new Medicare number for any individual who needs one. “The beneficiary calls Medicare and says, ‘I got a phone call that seemed shady and I need a new number,” explains Graves. “HMS will get that information by noon the next day and has a 24-hour turnaround to get the new number processed.”
Helping Vulnerable People
Why does HMS do this work? “It makes a difference because we care about vulnerable populations, including Medicare recipients,” says Graves. “We call beneficiaries who have these issues and do everything we can to make sure they maintain their coverage and help them to resolve any problems or questions. We are in this because we want to make sure they are well taken care of.”