Presentation on theme: "Introducing Electronic Submission of Medical Documentation (esMD)"— Presentation transcript:
1 Introducing Electronic Submission of Medical Documentation (esMD) 2015Introducing Electronic Submission of Medical Documentation (esMD)to Providers, Review Contractors, and Health Information Handlers (HIHs)The Centers for Medicare & Medicaid Services (CMS)Office of Financial Management (OFM)Provider Compliance Group (PCG)Division of Compliance Projects and Demonstrations (DCPD)
2 Benefits of using esMD Quicker turnaround: Providers have reported the payment turnaround when using esMD is 6 days as opposed to the paper process which is approximately 3 weeks.Reduce labor costs:esMD helps to reduce the amount of labor required to fulfill these requests by no longer having to print and mail paper, feed a fax machine or burn CD’s.Reduced hard costs:esMD can also reduce hard costs like shipping and handling expenses.
3 Background facts about improper payments The CMS Office of Financial Management estimates that:The fiscal year (FY) 2014 Medicare Fee-for-Service (FFS) program improper payment rate was 12.7 percent, representing $45.8 billion in improper payments.The FY 2013 Medicare FFS program improper payment rate was 10.1 percent, representing $36.0 billion in improper payments.Most improper payments can only be detected by a human comparing a claim to the medical documentation.Medicare Fee-for-Service 2013 Improper Payments Report
4 Background facts about medical documentation requests Medical Documentation Requests are sent by:Medicare Administrative Contractors (MACs) Medical Review (MR) DepartmentsComprehensive Error Rate Testing Contractor (CERT)Payment Error Rate Measurement Contractor (PERM)Medicare Recovery Auditors (formerly called RACs)Supplemental Medical Review Contractor (SMRC)Claim review contractors issue over 2 million requests for medical documentation each year.Claim review contractors currently receive most medical documentation in paper form or via fax.Medical documentation requests are also sent by:Overseen by:MAC Cost Report Audit DepartmentsOFM/FSGCoordination of Benefit ContractorsHITECH AuditorsQIOsOCSQQICsCM
5 The solution: Electronic Submission of Medical Documentation (esMD) Phase 1:Doc’n Request LetterelectronicWent live Sept 15, 2011electronicPhase 2:Planned for Future Release
6 Pre-esMD paper medical documentation process Doc’ n Request LetterReview ContractorPaper Medical RecordProvider
7 Administrative Contractors esMD phase 1: September 2011MedicareAdministrative ContractorsMedicareRecoveryAuditorsDoc’ n RequestLetterPERMCERTPDFPDFPDFPDFCONNECT CompatibleCMS Private NetworkContent Transport ServicesEFTGatewayBuilt byEFT built by TIBCO
8 esMD phase 2: Future release MedicareAdministrative ContractorsMedicareRecoveryAuditorsZPICsPERMCERTStructured Electronic Requests for Medical DocumentationPDFPDFPDFPDFPDFCMS Private NetworkContent Transport ServicesEFTCONNECT CompatibleEFT built by TIBCO
9 Current and future use cases for esMD INBOUND Use Cases Submitted through esMD (esMD Phase 1)Responses to Documentation Request Letters in PDFPower Mobility Device (PMD) Prior Authorization Requests in PDF1st level Appeal Requests in PDFAdvance Determination of Medicare CoveragePrior authorization request for ambulance in PDFPrior authorization request for HBO in PDFPrior authorization request in X12 278Structured Orders, Progress NotesStructured esMD Phase 2 RegistrationOUTBOUND (esMD Phase 2)Structured Outbound Documentation RequestsPower Mobility Device (PMD) Prior Authorization ResponsesPrior authorization responsesReview Results LettersDemand LettersLOOKUP (Future Phase)Request\Receive Documentation StatusRequest\Receive Claim StatusRequest\Receive Appeals StatusRequest\Receive Eligibility InfoWe Are HereWe Are Here
10 Prior Authorization (PA) of Power Mobility Devices (PMD) submissions through esMD EFTEFT built by TIBCOPrior Authorization Requests may be submitted directly to CMS via esMD. A Durable Medical Equipment (DME) supplier will obtain a letter of medical necessity and preauthorization from the provider and will submit the request for approval of health care based on medical necessity via esMD to CMS. The supplier will obtain preauthorization from the DME MAC before the request for DME is processed.
11 Definition of an esMD package A portion of a patient’s medical record in esMD format which will contain:Imaged documents (PDF)Important Metadata Fields:Intended Recipient – Required fieldClaim ID – Required field for ADRs onlyoptional for First Level Appeals requestsnot used for Prior Authorization RequestsNPI – Required fieldCase ID – Required field, if knownDocument Type Code – Required fieldResponse to Additional Documentation Request (PDF)Power Mobility Device (PMD) Prior Authorization Requests (PDF)Advance Determination of Medicare Coverage (ADMC)First Level Appeal Requests (PDF)Non-Emergent Ambulance TransportDetailed description for each field can be found in:the esMD XDR Profile.the esMD Implementation Guide.(http://www.connectopensource.org/product/connect-NHIN-specs)(www.cms.gov/esMD)
12 esMD is not mandatory for providers CMS recognizes that not all providers are adopting HIT solutions at the same pace.HIT Adoption RateLate AdopterStill using paper records.Intends to rely on fax machines, USPS, FedEx, etc. for the for the next 10 years.Average AdopterUsing imaged & electronic records.Will wait to see which esMD Service Providers emerge in their area (and at what price).Early AdopterHas used EHRs for years.Ready for esMD now!Review contractors cannot target providers for medical review just because they use esMD, CMS Program Integrity Manual Chapter 3, Section
13 esMD statisticsAs of February 20, 2015, over 84,477 providers have signed up with an esMD HIH.As of February 20, 2015, over 1,199,038 medical records have been submitted through the CMS esMD Gateway.
14 The eHealth exchange (formerly Nationwide Health Information Network) Is a set of standards, protocols, legal agreements, and specifications that a consortium of health information organizations have agreed are necessary for secure and private exchange of health information over the public internet.Is overseen by the Office of the National Coordinator for Health IT (ONC)Includes a standard for a secure “Gateway”Are not funded by CMS or ONCCMSDallas AreaProvidersesMD transactions are SAFE and SECURE becausethe esMD system uses NHIN standards
15 CMS esMD GatewayCMSDallas AreaProvidersCMS has built an Exchange Gateway to accept esMD transactions from providers.The CMS esMD Gateway went live September 15, 2011.CMS uses the “CONNECT” brand of gateway.
16 esMD is open to providers and provider networks:May communicate directly with providers, orMay communicate through entities who have formed a provider network
17 Medicare and Medicaid review entities can join the eHealth exchange Option 1:Join esMDOption 2:Build your own GatewayOption 3:Hire a Health Information Handler (HIH)or join a Health Information Exchange (HIE)(see slide 24 for more information)
18 Providers who want to submit via esMD STEP 1: Find out if your Review Contractors accept esMD STEP 2: Obtain access to an esMD “gateway”
19 Step 1: CMS Review Contractors that accept esMD Approved CMS Review ContractorsRegion A Medicare Recovery AuditorJA DME Durable Medical Equipment MACRegion B Medicare Recovery AuditorJB DME MACRegion C Medicare Recovery AuditorJC DME MACRegion D Medicare Recovery AuditorJD DME MACJ5 Medicare Administrative Contractor (MAC)Zone 1 Zone Program Integrity Contractor (ZPIC)J6 MACZone 2 ZPICJ8 MACZone 3 ZPICJ10MACZone 4 ZPICJ11MACZone 5 ZPICJ15 MACZone 7 ZPICJE MACU.S. Railroad Retirement Board (RRB)JF MACSupplemental Medical Review Contractor (SMRC)JH MACComprehensive Error Rate Testing (CERT)JK MACProgram Error Rate Measurement (PERM)JL MACJN MACFor updated list, visit:
20 esMD Review Contractors Participate voluntarilyReceive no funding from CMS or ONCAttend calls with CMS (scheduled)Obtain connectivity to the Electronic File Transfer systemSuccessfully onboard and test with the CMS esMD team
21 Step 2: How can providers obtain access to a Gateway?Providers can build their own gatewayProviders can contract with a Health Information Handler (HIH)
22 CMS-certified HIHs that offer esMD “Gateway” services CMS Certified esMD HIHsIVANS / ABILITY NetworkBluemark, LLCCobius Healthcare SolutionsCranewareDorado SystemsEpisode AlerteSolutions, Inc.HealthPortIOD IncorporatedLOISS, Ltd.Medical Electronic Attachment (MEA)MedFORCE TechnologiesMROProficient HealthRycan Technologies, Inc.RISARCSSISunCoast RHIO, Inc.Verisma SystemsNote: HIHs are not funded by CMS or ONCFor an updated list, visit:
23 Using Health Information Handlers to provide Gateway services A Health Information Handler (HIH) is any company that handles health information on behalf of a provider. Examples include:Health Information Exchange (HIE)/Regional Health Information Organization (RHIO)Release of Information (ROI) Vendor A company that manages the release of information for providers. Their services may include logging and tracking the request, retrieving the patient record from multiple locations in multiple formats, identifying the information needed to fulfill the request, requesting additional authorization, if needed, copying, packaging and mailing, and invoicing.Electronic Health Record (EHR) VendorClaim ClearinghouseHealth Internet Service Provider (HISP)An entity that provides services that enable providers or healthorganizations to exchange health information using the internet.
24 CMS does not dictate how an HIH communicates with providers Some esMD HIHs plan to ingest a provider's medical records and metadata by:going onsite to the provider's facilityusing a Virtual Private Network (VPN)using a secure web portalSome esMD HIHs are considering using DIRECT.VPND I R E C TD I R E C T
25 esMD Health Information Handlers (HIHs) esMD HIHs:Participate voluntarilyReceive no funding from CMS or ONC (Note: they may bill providers)Attend calls with CMS (scheduled)Build a CONNECT-Compatible GatewayObtain a certificate, IP address, and share key with CMS Gateway ContractorSuccessfully onboard with the CMS esMD team and test with CMS Gateway ContractorRecruit providers to join
26 Want to be an esMD HIH but don’t know how to build a Gateway? Consider contacting the esMD HIHsConsider contacting one of the esMD HIH subcontractorsConsider contacting one of the IT vendorsVisit the CMS and QSSI websites
27 For more information To contact the esMD Team: esMD@cms.hhs.gov CMS esMD Website:CONNECT Website:Follow Us on Twitter: @CMSGov (Look for #CMS_esMD)