What You Need to Know About the Social Security Number Removal Initiative

May 11, 2017

The Honorable Seema Verma Administrator

Centers for Medicare & Medicaid Services

U.S. Department of Health and Human Services Hubert H. Humphrey Building, Room 445–G 200 Independence Avenue, SW

Washington, DC 20201

Re: Social Security Number Removal Initiative Dear Administrator Verma:

The undersigned organizations are writing to express concern over the Centers for Medicare & Medicaid Services’ (CMS) planned enactment of the Social Security Number Removal Initiative (SSNRI). As explained below, this initiative has the potential to significantly disrupt patient care and physician payment. Accordingly, we recommend that CMS pursue this change through the traditional notice and comment rulemaking process so that valuable industry feedback may be considered. We further ask that CMS develop a mechanism for providers to quickly and securely access Medicare beneficiary identification numbers to avoid disruptions in access to care.

Background

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 included a provision requiring CMS to remove the Social Security Number (SSN) from Medicare cards due to concerns of identity theft.

The process CMS has developed to implement this requirement is referred to as the SSNRI. CMS currently uses a Health Insurance Claim Number (HICN), based on an individual’s SSN, as a patient’s Medicare beneficiary identification number. To implement the SSNRI, CMS will create new Medicare Beneficiary Identifiers (MBIs), first for the 60 million active Medicare beneficiaries and then for 90 million deceased beneficiaries, to replace the HICN on beneficiary identification cards.

Starting in January 2018, CMS plans to conduct outreach and education to beneficiaries to alert them of the transition from the HICN to the MBI. New identification cards displaying the MBI will be sent to beneficiaries in phases over a twelve-month period beginning April 1, 2018. CMS, however, does not plan to disclose the details of how the cards will be sent (e.g., alphabetically, by state or region, etc.).

While CMS will accept both HICNs and MBIs in administrative transactions during the transition period (April 1, 2018 – December 31, 2019), providers’ systems must be ready to accept the MBI by April 2018 and must exclusively use the MBI starting January 1, 2020. CMS will provide MBIs in remittance advice for part of the transition period (beginning in October 2018), but there will be no mechanism for providers to obtain a patient’s MBI after January 1, 2020 – even if a patient’s first appointment with a particular provider after being assigned an MBI occurs after the transition period.  This scenario is particularly likely for patients receiving new cards towards the end of the issuing cycle and for provider types, such as specialists, from whom the patient may not seek frequent care.

As explained in more detail below, we are concerned about a provider’s inability to access a patient’s MBI both during and following the transition. If a patient does not bring his or her MBI to his or her appointment, significant delays in patient care or provider reimbursement could result due to the lack of a mechanism for the provider to look-up the patient’s MBI.

Transition Concerns

While we understand the importance of protecting Medicare beneficiaries from identify theft by replacing SSNs with new MBIs on Medicare identification cards, we have concerns about patient and physician awareness of this change and backup plans to mitigate potential problems. In a September 23, 2016 letter responding to providers’ request for traditional rulemaking concerning the SSNRI, CMS characterized the majority of needed changes as being “operational in nature”, making a regulatory review and comment process unnecessary. We respectfully note that this change will impact all Medicare beneficiaries and that all systems and business processes will need to be able to accept and process the new MBI. We therefore urge CMS to work with stakeholders to avoid significant problems and again recommend that CMS instead pursue this change through the traditional notice and comment rulemaking process so that valuable industry feedback on SSNRI implementation may be obtained and considered.

Furthermore, multiple provider groups have expressed overwhelming concern regarding the lack of a contingency system that will allow medical practices to obtain the MBI for a patient who arrives at an appointment without a new Medicare card. This lack of a provider look-up system may strain a practice’s ability to conduct administrative transactions and delay patient care in the event that a patient does not present his or her card at the time of service.  In addition, family members managing the patient’s care and affairs may not have access to the new card. Providers have offered a range of potential solutions— including look-up databases, providing MBIs in electronic eligibility responses, and secure phone systems—to both protect sensitive MBI data and allow practices to access the information needed to continue providing timely care to Medicare patients. An SSNRI transition plan that is totally dependent upon patient presentation of new Medicare cards to providers will result in delayed treatment and claim payment.

We have the following additional concerns about the SSNRI transition process:

Beneficiary confusion about new cards:  We are concerned that beneficiaries will not understand why they are getting a new card and will throw it away or misplace it, especially since CMS does not plan to initiate outreach and education to the Medicare population until January 2018—just three short months before the beginning of the SSNRI transition. We believe that this short window for educational outreach will be insufficient to prepare the large and vulnerable Medicare population for this major transition, and we urge CMS to initiate an extensive communications campaign to beneficiaries at a much earlier date.

• Lack of knowledge of phased rollout of new cards: CMS has said that, for security purposes, it will not provide information on when new identification cards will be sent to beneficiaries, which means practices will not know when to ask their patients for their new card. Through targeted notification to impacted providers, CMS could inform practices of new card distribution and still avoid the broadcast communications that could potentially alert fraudsters.
• MBI not provided in eligibility responses: CMS’ plan to include the MBI in remittance advice during the transition period is not the optimal solution within the current provider workflow. Inclusion of the patient’s MBI in the eligibility response would be of far greater utility to practices, as the information would be available at the beginning of the care episode, when and where providers routinely seek and obtain benefit and coverage information. Existing patient intake and scheduling systems will be disrupted if the MBI is not available via the eligibility response, and time and resources spent ascertaining MBIs will lead to practice inefficiencies that could reduce the hours available for direct care of Medicare patients. Patients would also benefit from inclusion of the MBI in eligibility responses, as this would reduce confusion and apprehension about eligibility for services at the earliest point in care.
• Insufficient industry education and preparation: The conversion to the MBI will require significant workflow and system changes for providers, practice management system vendors, and secondary payers. Discussions at CMS-organized listening sessions and forums about the SSNRI suggest widespread confusion and lack of readiness throughout the industry for this major transition. We urge CMS to increase education and outreach efforts to all affected stakeholders to ensure adequate industry preparation for SSNRI implementation.

In an age of increased identity theft and fraud, the Medicare patient population deserves the improved security that will be achieved with the SSNRI. This protection should not, however, come at the expense of prompt patient care or provider payment. We urge CMS to consider adjusting the implementation of the SSNRI as outlined above to protect care access for our nation’s seniors. We appreciate your attention to this matter.

Sincerely,

American Medical Association

American Academy of Allergy, Asthma & Immunology

American Academy of Dermatology Association

American Academy of Emergency Medicine

American Academy of Family Physicians

American Academy of Otolaryngology—Head and Neck Surgery

American Academy of Orthopaedic Surgeons

American Academy of Physical Medicine and Rehabilitation

American Association of Neurological Surgeons

American Association of Otolaryngic Allergy

American College of Emergency Physicians

American College of Physicians

American College of Rheumatology

American College of Surgeons

American Congress of Obstetricians and Gynecologists

American Gastroenterological Association

American Orthopaedic Foot & Ankle Society

American Osteopathic Association

American Psychiatric Association

American Society for Clinical Pathology

American Society for Dermatologic Surgery

Association American Society for Surgery of the Hand

American Society of Anesthesiologists

American Society of Cataract and Refractive Surgery

American Society of Clinical Oncology

American Society of Dermatopathology

American Society of Hematology

American Society of Plastic Surgeons

American Society of Retina Specialists

American Urological Association

American Academy of Ophthalmology

Association of American Medical Colleges

College of American Pathologists

Congress of Neurological Surgeons

Infectious Diseases Society of America

Medical Group Management Association

National Association of Medical Examiners

North American Spine Society

Obesity Medicine Association

Renal Physicians Association

Society of Critical Care Medicine

Society of Nuclear Medicine and Molecular Imaging

Spine Intervention Society

Medical Association of the State of Alabama

Arizona Medical Association

Arkansas Medical Society

California Medical Association

Colorado Medical Society

Connecticut State Medical Society

Medical Society of Delaware

Medical Society of the District of Columbia

Florida Medical Association Inc

Medical Association of Georgia

Hawaii Medical Association

Idaho Medical Association

Illinois State Medical Society

Iowa Medical Society

Kansas Medical Society

Kentucky Medical Association

Louisiana State Medical Society

Maine Medical Association

MedChi, The Maryland State Medical Society

Massachusetts Medical Society

Michigan State Medical Society

Minnesota Medical Association

Mississippi State Medical Association

Missouri State Medical Association

Montana Medical Association

Nebraska Medical Association

Nevada State Medical Association

New Hampshire Medical Society

Medical Society of New Jersey

New Mexico Medical Society

Medical Society of the State of New York

North Carolina Medical Society

North Dakota Medical Association

Ohio State Medical Association

Oklahoma State Medical Association

Oregon Medical Association

Pennsylvania Medical Society

Rhode Island Medical Society

South Dakota State Medical Association

Tennessee Medical Association

Texas Medical Association

Utah Medical Association

Vermont Medical Society

Medical Society of Virginia

Washington State Medical Association

Wisconsin Medical Society

Wyoming Medical Society