Medicare Public Use Files

CMS has provided access to data collected through the administration of claims to researchers since 2003 through the PUF (Public Use Files).  These files contain useful information on patients going back to 1999.  These files are offered for free as CSV (spreadsheet) files and offer valuable information on specific healthcare services.

These files are designed for researchers, but for you number crunchers out there, they can provide valuable insight into industry trends and how your own organization compares to your competitors.

For example, the current PUF file on hospice beneficiaries contains data for 2010 for a total of 56,943 beneficiaries.  The file contains eight pieces of information for each one.  These totals come from the data dictionary and code book describing this file.  The totals themselves are very interesting:

Public Use Files
Medicare Public Use Files

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Evolution and Healthcare IT

When I was taught the theory of evolution in school, I was under the impression that species evolved slowly, over millions of years, leading steadily toward more advanced life forms more capable of dealing with their environment.  I can still remember the  March of Progress or the “ape to man” illustrations of earlier versions of our species, each appearing to be more like us and standing more upright as you moved left to right through the images.

As an adult, I learned more about how evolution actually worked.  In nature, it never was a straight line from less efficient species to more efficient ones.  The reality was that nature adapted to its environment through trial and error.  For every advancement through genetic mutation, millions of mutations created less efficient organisms that never survived.  In addition, from time to time, mass extinction events wiped out a majority of the species on earth leaving nature to start over, nearly from scratch.  This lead to two different evolutions of dinosaurs and the eventual rise of the mammals.

March of Progress
Matt Groening – Homersapien


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Big Brother Versus the Integrity of Healthcare Data

In my previous article, we discussed the issues surrounding the National Provider Identifier (NPI) and the Health Plan Identifier (HPID). The NPI has been successfully implemented, the HPID is delayed indefinitely. The last required identifier remaining to be implemented from the original HIPAA legislation is the National Patient Identifier (also NPI) sometimes referred to as Master Patient Index (MPI). The intent of this code set is to create and assign a unique ID to every patient who receives healthcare in the United States.

This code set is intended to address the “holy grail” of healthcare IT, the ability to relate patient data for an individual collected by different entities and for different encounters into a single integrated medical record. The benefits of this achievement seem fairly obvious. Clinical data could be shared and updated by all providers interacting with a patient. The quality of care would improve and medical mistakes would be reduced.

master patient index

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Zen and the Art of Revenue Cycle Maintenance

In 1974, Robert Pirsig wrote a popular philosophical novel (Zen and the Art of Motorcycle Maintenance) that dealt with the concept that “Quality” and striving for perfection is an important practice and lifestyle that contributes to spiritual growth. The author felt that the metaphysical question “What is best?” is at least as important and the more popular “Why are we here?” He believed that beauty and personal gratification could be found in the effort of perfecting a process. In his book, he says “Quality is Buddha” and compares striving to improve a process to the scientific effort to determine “the truth”, like the effort to determine a unifying theory in physics. The author takes these grandiose metaphysical concepts and provides practical examples. He shows that changing your concept of your environment can create positive change. By looking at things in a new way, you can see things you did not see before and make things better.

In business, we often take the path of least resistance. We develop processes to support business transactions and then we repeat them over and over until they experience some sort of major failure that requires a correction. If someone asks, why do we do things this way? The answer is most often “this is the way it has always been done”. We rarely take the time to review our processes at a fundamental level and ask ourselves philosophical questions like “why do we do this?” or “is this the best way?”
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ANSI 278 – Services Authorization – The Lost HIPAA Transaction

In 1996, HIPAA introduced new required electronic formats for some of the common transactions used today for the processing of insurance claims and related activities. As I discussed in my last article, these transactions have had disappointing adoption rates considering how long they have been available and the benefit they would bring the industry if they were universally adopted.


When these standards were introduced with the initial HIPAA legislation, another electronic transaction standard was also included, the ANSI 278 – Request for Review and Response. This is also referred to as the “Prior Authorization” transaction. The intent of this standard was to create a uniform automated process for requesting the authorization of a specific service from a health plan prior to the delivery of the service. In the absence of the adoption of this standard, providers and health plans must participate in many different unique processes of obtaining this authorization that cause delays in the processing of claims and the frequent delivery of services that are never paid for by insurance.

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HIPAA Transaction Adoption Rates

CAQH (Council for Affordable Quality Healthcare) conducts an annual study of the adoption rates for commonly used HIPAA transactions in the healthcare industry.  A copy of this study can be obtained through this link:

This data is for the 2013 calendar year.  Based on the comments provided in the report, it is apparent that they feel that there has been significant progress in the implementation of these transactions.  As a vendor that provides systems that use them in revenue cycle management, the growth seems painfully slow. Continue reading

CMS Contractor End-to-End testing and MEDTranDirect

As we approach the deadline for implementation of ICD10, opportunities present themselves to examine our preparedness as software vendors and providers for the processing of claims containing these new codes. CMS has been ready to implement ICD10 in their claims adjudication systems since 2011. Since then, as the deadline was extended, they have made changes to their systems quarterly to fine tune them prior to October.

CMS has implemented a testing strategy beginning late last year that allows any provider to submit test claim files with ICD10 codes and review the 999 and 277CA response files returned. If you submit your claims directly to Medicare, CMS encourages you to participate in these tests. If you submit your Medicare claims through a clearinghouse, they will need to conduct these tests instead of you.

The details of CMS ICD10 testing policies are provided in this MLN Matters announcement.


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Meaningful Use for Health Plans

Recently, I attended the CAQH CORE ( webinar discussing the issues and events expected to be dealt with during 2015.  This organization is responsible for establishing the operating rules for the exchange of HIPAA transactions.  While everyone is focused on ICD10, I believe that the work being performed through this organization will have a major impact on the healthcare industry as well.cadaceus_asterisk

The HIPAA legislation, back in 1996, established the initial specs for the electronic exchange of information used in specific healthcare transactions.  As part of the ACA, operating rules are being established through CAQH CORE to require all healthcare business partners to use these transactions instead of alternative methods for documenting these business processes.  For fifteen years, the intended benefit of using these transactions has not been realized.  The reason is not that the standards are not adequate, but that they are of limited benefit unless everyone uses them. Continue reading

CAQH CORE Offers free EFT Enrollment Tool

On the CAQH CORE web site, there is a tool that allows providers to enroll in EFT with multiple payers in a single step. This link will take you to the site:


After you create an account, you can upload an image of a check, select the payers you want to enroll with from their list, and the enrollment information will be sent to each one. Continue reading

Electronic Transaction Adoption Rates

CAQH CORE is the organization overseeing the adoption of HIPAA transactions as part of the ACA mandated adoption of these transactions. During 2013, the eligibility transaction (270/271) and the claim status transaction (276/277) became mandated for use by all HIPAA eligible entities. At the beginning of 2014, rules pertaining to EFT and the 835 electronic remittance came into effect.

CAQH CORE has reported the adoption rates for electronic transactions as of the end of 2013. These numbers represent the percentage of these transactions that are conducted electronically of the total of all transactions of these transaction types.

Transaction      Adoption Rate
Claims Submission 91%
Eligibility Verification 81%
Claim Status Inquiry 72%
Claim Payments 56%
Remittance Advice 53%
Prior Authorization 15%

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