Black Box Edits (Medicare)

The 1997 Balanced Budget Act instructed HCFA that they had to reduce payouts to doctors.  The method selected is to add additional edits, on top of the National Correct Coding Initiative, excluding coding pairs for payment.  They selected a commercial company, HBOC, whose product, GMIS Claim Check is used by many third party payors.  Experience has shown that the GMIS Claim Check edits are irrational, unreasonable and arbitrary.  Unlike the National Correct Coding Initiative, they take no lead from professional societies and the logic of considering procedures components of each other or mutually exclusive.  For example, the American College of Radiology and HCFA through the National Correct Coding Initiative do not consider a trans abdominal 
ultrasound bundled with a trans vaginal ultrasound.  However, the commercial edits used by third parties consider these two procedures bundled and only pay for one when both are billed.  

So, HCFA is adding edits from HBOC and GMIS Claim Check.  Since this is a HCFA policy, we consider this a reality.  However, the problem is with the elimination of citizens’ right to freedom of information, as provided by the Freedom of Information Act (FOIA).  HCFA has indicated that non of these commercial edits will be publicized because of their proprietary nature with HBOC.  This goes against all principles of the FOIA.

There is a reason that the non publishing of these edits, now called “black box edits” is of major concern for providers of healthcare services.  Unfortunately, valid claims are denied as a matter of course in the processing of payor claims.  Qualified personnel are able to identify these improper denials and have the ammunition to fight their denial, resulting in final proper payment.  The ammunition that is used includes the information 
of correct coding procedures, HCFA regulations, specific carrier policies and listings of all coding pairs considered mutually exclusive or component parts of each other.  With these “black box edits” we are unable to verify denials, fight for proper payment or be assured that the claim had been processed correctly.  Historically no one can argue that valid claims are not paid some percentage of the time, and without our FOIA rights, our hands are being tied to even determine the appropriateness of denials and to fight for proper payment.

Barbara J. Cobuzzi, CPC