MPSM Releases Sept. Newsletter

Program News: Inquiring Minds Want to Know: What is the Progress on the Dental MVP?

MPSM teams continue to make progress toward the dental minimum viable product (MVP), developing functionality for the end-to-end processing of a dental claim. In addition to the existing dental teams, (Dental Claims Ingestion, Dental Beneficiary Validation, and Modern Claim Adjudication Development Services) other teams have been formed to support the effort. Their work involves making changes in MCS to send dental claims to HIGLAS so they can be paid, validating relationships between claim submitters and providers using a mainframe VSAM file, and generating a robust set of test claims.

As of August 2023, the teams have accomplished the following milestones related to Medicare Administrative Contractors (MACs) and validations:

• MACs can see ingested claims and retrieve claim acknowledgment files (base shell for 999 and 277CA transactions) for submitted claims.
• The VSAM team created a low-level API that allows the DCI team to access and query the VSAM provider control file (PCF) on the mainframe to perform validations and send appropriate file acceptance or rejection information to MACs.
• The system can take an ingested claim and determine whether it should be accepted based on the beneficiary’s information and apply a price to it.
• The MVP can generate and assign an Internal Control Number (ICN) and apply the amount charged on the claim to the beneficiary’s deductible.

Initial connectivity with MCS has been established enabling MPSM to send initial data from the adjudication application to MCS – a critical step towards leveraging MCS integrations with HIGLAS to process adjudicated dental claims from the cloud-based dental claims processing system for payment issuance and remittance generation. 

Testing, Testing, 1, 2, 3

Meet Synthea, the newest MPSM team formed to support dental MVP needs by generating synthetic test data. The team gets its name from Synthea™, an open-source, synthetic patient and health data generator that models the medical history of synthetic patients. Using the Synthea™ product will provide MPSM with high quality, “realistic but not real,” faux data that does not cause privacy or security risks. Synthea will first be used to test 837D claims and eventually will be utilized for 837I and 837P claims. Synthea is an exciting new addition to the program and will further MPSM’s strides towards completing the dental MVP. 

To learn more about Synthea, reach out to Cynthia Miles (Fed PM); Jason Walonoski (Technical Lead); Marc Hadley (Lead Developer); and Toan Luong (Project Leader). 

Leadership Spotlight: Bonnie Hockaday 

"We Are MPSM" provides an opportunity to take a glimpse into leaders and product managers’ vision of MPSM, hear their views on the importance of modernization, and learn some fun facts about them along the way. The series continues with Bonnie Hockaday, Deputy Director of the Division of Shared Systems Management (DSSM).

Who is Bonnie Hockaday?

Bonnie began her career at CMS in the Division of Shared Systems Management (DSSM) where she has worked her way up to become the Deputy Director. Prior to that, she was the production support project manager on the FISS contract.

“My entire career has been in the Medicare ecosystem either as a contractor or as a CMS employee,” Hockaday says. “I began as a Medicare claims processor. At the time, claims were hand coded but within a matter of months, computers made their debut and the technology quickly evolved after that. Throughout my career, management and service have been central themes. It has been my pleasure and honor to have worked with so many individuals who are dedicated to the Medicare program.”​​

What is the Significance of Modernization for CMS?

In 2017, it was exciting to begin proofs of concept on modernizing the Medicare Fee-For-Service claims processing system. The modernization effort has expanded a greatly since those early days. Modernization of the legacy claims processing systems is vital to CMS, specifically, ensuring the ability to process claims accurately and in a timely manner. Not only is the modernization of legacy systems crucial to CMS, but also to the nation’s economy and to an effective health care system. 

Most Significant Accomplishment at CMS:

Beginning the Agile transformation of the Shared Systems and DSSM team is a significant accomplishment. I am very proud of the team and their contributions to this effort both with the Shared Systems and with other stakeholders in the Medicare FFS ecosystem.

Your Career in 5 Words:

Adapting,​Challenging,​ Adventurous,​Thriving,​ Serving​ 

This Year Has Been…

Change, change, and more change!​ 

What Do You Do in Your Free Time?

I spend time with my sons and grandchildren, traveling, playing with our fur babies, trying new things, practicing Dances of Universal Peace and quiet contemplation.

How Did You Spend Your Summer?

This year my husband and I took a memorable cruise along the coast of Mexico’s Yucatan peninsula. The highlights of the trip were swimming with the dolphins, a memory to cherish and climbing atop Mayan ruins, a view to behold.

Team Spotlight: MCS Team Tests New Idea for Cloud-Based Claims Processing

The Multi-Carrier System (MCS) team is working on a Proof of Concept (PoC) that converts a mainframe COBOL program from MCS into the Amazon Web Services (AWS) cloud. The goal is to utilize the benefits the cloud provides like reliability, scalability, reusability, and flexibility for faster changes and modern data formats for easy processing. 

Modernization results in several efficiencies:

• The program runs on-demand rather than in batch cycles – improving the speed at which inputs are processed.
• Using a modern programming language and processes will increase the pool of developers that can support the ongoing work as opposed to the outdated COBOL code.
• With the current system, it can take months to implement code changes. The use of Continuous Integration (CI) and Continuous Delivery (CD) processes in the cloud reduces the amount of time it takes to implement changes from months to seconds - deploying changes to AWS is as fast and easy as clicking a button. 
• Testing can be automated allowing errors to be identified early in the development cycle. 

This PoC can serve as a blueprint for modernizing other COBOL programs and leveraging AWS cloud capabilities and modern technologies. Click here (Confluence/EUA Required) to read more about this PoC.

Digital Service at CMS (DSAC) recently completed a research study meant to provide insights about the state of technology and software commonly used by dental providers in the industry—i.e., practice management software and clearinghouses. DSAC also wanted to identify gaps that might discourage providers from participating in Medicare and otherwise inform the dental claims processing implementation.

Research Spotlight: DSAC - Dental Software Study

Over a two-month period in 2023, DSAC conducted market research and spoke with dental software vendors and clearinghouses. The study examined how practice management software and dental clearinghouses form relationships. Based on the analysis of those relationships and how they interconnect, DSAC concluded that Medicare needs to connect with about 5 clearinghouses to reach most dental providers and most of those clearinghouses have an existing relationship with Medicare.

The study also explored the capabilities and limitations of the software. Here are some key insights.

• Software models: On-premise and cloud-hosted software models continue to be prevalent in the dental industry. These software models slow the speed at which providers can adopt changes when compared to cloud-native software. It can take 4 months to upward of 2 years for providers to get access to new features under those two software models.
• ICD codes: There is generally basic support for up to four ICD codes in dental software. However, the tools available to help providers find a code vary in sophistication and usefulness, potentially adding administrative burden to some providers.
• Quality of transaction responses: The quality of the data in transaction responses from payers is important to create a consistent representation of the claim while it is with the payer. Poor transaction quality influences what transactions clearinghouses can rely on to convey things like claim status to providers.
• Clearinghouse submission expectations: Clearinghouses will likely want to set up service-level agreements (SLAs) with a payer and can expect to receive claims in batches. DSAC concluded that there should be internal agreement on what thresholds are accomplishable for the MVP and if any requirements around the claim batch structure should be established.

Overall, DSAC heard from both clearinghouses and software vendors that if Medicare follows industry norms (i.e., uses the dental claim form, 5010 version, and standard interfaces like sFTP), there should be little impact on clearinghouses, vendors, or providers. However, both said they wanted to see Medicare’s billing requirements to better assess the impact.

Research Spotlight: Medicare Part B Claims Processing: A Fresh Perspective from the Strategic Design Team!

The Strategic Design team recently embarked on research that seeks to transform the way you understand Medicare's complex ecosystem of claims payment systems and processes using a human-centered design (HCD) approach. 

By putting you (a human!) at the center of the process, the goal is to create a shared mental model, a jargon-free vocabulary that resonates, and a pathway to open communication that enables everyone -- from software developers, to designers, to analysts - to better understand how Medicare fulfills one of its core responsibilities: paying claims. 

The Strat Design team proposed a complementary approach, centered around 3 key insights, to answer the question: “What are all the ways a Part B claim can change throughout its life?”

Insight 1: At the core of Part B claims processing, is a linear sequence of phases, (Claims Intake, Adjudication, Accounting, and Post-Pay Adjustments) with pivotal events separating them.

Insight 2: A claim has a singular state which can change in specific ways and during specific phases throughout claims processing:

• Claims intake: Has the claim been accepted or rejected?
• Adjudication: Was the claim paid, denied, or returned as unprocessable?
• Post-pay adjustments: Has the claim been appealed or reopened?

Insight 3: Knowing how and when a claim is permitted to change enables design of a data model that can effectively represent it. The team termed this the Mutability of a Claim Record.

Although it may seem obvious or simple, this is the foundation for productive conversations between team members with varying roles and expertise as we all seek to further MPSM's mission of building better, more agile, and sustainable products.