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2015 Introducing Electronic Submission of Medical Documentation (esMD) to Providers, Review Contractors, and Health Information Handlers (HIHs)

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Presentation on theme: "2015 Introducing Electronic Submission of Medical Documentation (esMD) to Providers, Review Contractors, and Health Information Handlers (HIHs)"— Presentation transcript:

1 2015 Introducing Electronic Submission of Medical Documentation (esMD) to Providers, Review Contractors, and Health Information Handlers (HIHs)

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. 2

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 3

4 Background facts about medical documentation requests  Medical Documentation Requests are sent by: Medicare Administrative Contractors (MACs) Medical Review (MR) Departments Comprehensive 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/FSG Coordination of Benefit ContractorsOFM/FSG HITECH AuditorsOFM/FSG QIOsOCSQ QICsCM 4

5 The solution: Electronic Submission of Medical Documentation (esMD) Phase 1: Doc’n Request Letter electronic Phase 2: Went live Sept 15, 2011 Planned for Future Release 5

6 Review Contractor Provider Doc’ n Request Letter Paper Medical Record Pre-esMD paper medical documentation process 6

7 esMD phase 1: September 2011 EFT CONNECT Compatible Doc’ n Request Letter Medicare Administrative Contractors Medicare Recovery Auditors PERM CMS Private Network PDF CERT PDF Content Transport Services Gateway Built by EFT built by TIBCO 7

8 esMD phase 2: Future release Content Transport Services Structured Electronic Requests for Medical Documentation CONNECT Compatible Medicare Recovery Auditors PERM EFT PDF CERT PDF Medicare Administrative Contractors ZPICs PDF 8 EFT built by TIBCO CMS Private Network

9 Current and future use cases for esMD We Are Here INBOUND Use Cases Submitted through esMD (esMD Phase 1)  Responses to Documentation Request Letters in PDF  Power Mobility Device (PMD) Prior Authorization Requests in PDF  1 st level Appeal Requests in PDF  Advance Determination of Medicare Coverage  Prior authorization request for ambulance in PDF  Prior authorization request for HBO in PDF  Prior authorization request in X  Structured Orders, Progress Notes  Structured esMD Phase 2 Registration OUTBOUND (esMD Phase 2)  Structured Outbound Documentation Requests  Power Mobility Device (PMD) Prior Authorization Responses  Prior authorization responses  Review Results Letters  Demand Letters LOOKUP (Future Phase)  Request\Receive Documentation Status  Request\Receive Claim Status  Request\Receive Appeals Status  Request\Receive Eligibility Info We Are Here 9

10 Prior Authorization (PA) of Power Mobility Devices (PMD) submissions through esMD 10 Prior 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. EFT built by TIBCO EFT

11 A portion of a patient’s medical record in esMD format which will contain:  Imaged documents (PDF)  Important Metadata Fields : Intended Recipient – Required field Claim ID – Required field for ADRs only o optional for First Level Appeals requests o not used for Prior Authorization Requests NPI – Required field Case ID – Required field, if known Document Type Code – Required field o Response to Additional Documentation Request (PDF) o Power Mobility Device (PMD) Prior Authorization Requests (PDF) o Advance Determination of Medicare Coverage (ADMC) o First Level Appeal Requests (PDF) o Non-Emergent Ambulance Transport Definition of an esMD package Detailed description for each field can be found in: the esMD XDR Profile. the esMD Implementation Guide. (www.cms.gov/esMD) (http://www.connectopensource.org/product/connect-NHIN-specs) 11

12 esMD is not mandatory for providers CMS recognizes that not all providers are adopting HIT solutions at the same pace. Late Adopter Still using paper records. Intends to rely on fax machines, USPS, FedEx, etc. for the for the next 10 years. Average Adopter Using imaged & electronic records. Will wait to see which esMD Service Providers emerge in their area (and at what price). Early Adopter Has 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  As 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. esMD statistics 13

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 ONC esMD transactions are SAFE and SECURE because the esMD system uses NHIN standards 14

15 CMS esMD Gateway  CMS has built an Exchange Gateway to accept esMD transactions from providers.  The CMS esMD Gateway went live September 15,  CMS uses the “CONNECT” brand of gateway. 15

16 esMD is open to providers and provider networks:  May communicate directly with providers, or  May communicate through entities who have formed a provider network 16

17 Medicare and Medicaid review entities can join the eHealth exchange  Option 1: Join esMD  Option 2: Build your own Gateway  Option 3: Hire a Health Information Handler (HIH) or join a Health Information Exchange (HIE) (see slide 24 for more information) 17

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” 18

19 Step 1: CMS Review Contractors that accept esMD For updated list, visit: 19

20 esMD Review Contractors esMD Review Contractors:  Participate voluntarily  Receive no funding from CMS or ONC  Attend calls with CMS (scheduled)  Obtain connectivity to the Electronic File Transfer system  Successfully onboard and test with the CMS esMD team 20

21 Step 2: How can providers obtain access to a Gateway?  Providers can build their own gateway  Providers can contract with a Health Information Handler (HIH) 21

22 22 CMS-certified HIHs that offer esMD “Gateway” services  Note: HIHs are not funded by CMS or ONC  For 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: (1)Health Information Exchange (HIE)/Regional Health Information Organization (RHIO) (2)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. (3)Electronic Health Record (EHR) Vendor (4)Claim Clearinghouse (5)Health Internet Service Provider (HISP) An entity that provides services that enable providers or health organizations to exchange health information using the internet. 23

24  Some esMD HIHs plan to ingest a provider's medical records and metadata by: going onsite to the provider's facility using a Virtual Private Network (VPN) using a secure web portal  Some esMD HIHs are considering using DIRECT. VPN CMS does not dictate how an HIH communicates with providers D I R E C T 24

25 esMD Health Information Handlers (HIHs) esMD HIHs:  Participate voluntarily  Receive no funding from CMS or ONC (Note: they may bill providers)  Attend calls with CMS (scheduled)  Build a CONNECT-Compatible Gateway  Obtain a certificate, IP address, and share key with CMS Gateway Contractor  Successfully onboard with the CMS esMD team and test with CMS Gateway Contractor  Recruit providers to join 25

26 Want to be an esMD HIH but don’t know how to build a Gateway? Consider contacting the esMD HIHs Consider contacting one of the esMD HIH subcontractors Consider contacting one of the IT vendors Visit the CMS and QSSI websites 26

27 For more information To contact the esMD Team : CMS esMD Website: CONNECT Website: Follow Us on (Look for #CMS_esMD) 27

28 Questions 28


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