esMD - Centers for Medicare & Medicaid Services

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Introducing Electronic Submission of Medical Documentation (esMD) to Providers MELANIE COMBS-DYER, RN Deputy Director, CMS / OFM / Provider Compliance Group August 2011

Transcript of esMD - Centers for Medicare & Medicaid Services

Page 1: esMD - Centers for Medicare & Medicaid Services

Introducing Electronic Submission of Medical Documentation (esMD) to Providers

MELANIE COMBS-DYER, RNDeputy Director,CMS / OFM / Provider Compliance Group

August 2011

Page 2: esMD - Centers for Medicare & Medicaid Services

Improper Payments

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www.paymentaccuracy.gov

Medicare receives 4.8 M claims per day.

CMS’ Office of Financial Management estimates that each year

• the Medicare FFS program issues more than $34.3 B in improper payments (error rate 2010:10.5%)

• the Medicaid FFS program issues more than $22.5 B in improper payments (3 year rolling error rate: 9.4%)

Most improper payments can only be detected by a human comparing:

• a claim to

• the medical documentation.

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Background Facts about Medical Documentation Requests

Medical Documentation Requests are sent by:

• Medicare Administrative Contractors (MACs)

• Comprehensive Error Rate Testing Contractor (CERT)

• Payment Error Rate Measurement Contractor (PERM)

• Medicare Recovery Auditors (formerly called RACs)

Claim review contractors issue over 2 million requests formedical documentation each year.

Claim review contractors currently receive most medical documentation in paper form or via fax.

Claim review contractors currently receive a tiny number of imaged documents in CD/DVD form.

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Today’s Paper World

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Today’s Medical Documentation Process

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Review Contractor

Provider

Doc’ n Request

Letter

Paper Medical Record

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The Solution: Electronic Submission of Medical Documentation (esMD)

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Phase 1: Doc’n

Request Letter

electronic

electronic

electronic

Phase 2:

Goes Live in Sept 2011

Scheduled to Go Live in about October 2012

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esMD is NOT mandatory

CMS recognizes that not all providers are adopting HIT solutions at the same pace.

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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!

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The 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)

is comprised of two parts:• Direct – designed for an individual to individual submission of health

information http://wiki.directproject.org/

• Exchange – designed for computer to computer exchange of health information http://healthit.hhs.gov/portal/server.pt?open=512&objID=1407&parentname=CommunityPage&parentid=8&mode=2&in_hi_userid=11113&cached=true

http://wiki.directproject.org/�
http://healthit.hhs.gov/portal/server.pt?open=512&objID=1407&parentname=CommunityPage&parentid=8&mode=2&in_hi_userid=11113&cached=true�
http://healthit.hhs.gov/portal/server.pt?open=512&objID=1407&parentname=CommunityPage&parentid=8&mode=2&in_hi_userid=11113&cached=true�
http://healthit.hhs.gov/portal/server.pt?open=512&objID=1407&parentname=CommunityPage&parentid=8&mode=2&in_hi_userid=11113&cached=true�
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CMS esMD Gateway

CMS is building an Exchange Gateway to accept esMD transactions from providers.

The CMS esMD gateway goes live in September 2011!

CMS uses the “CONNECT” brand of gateway.

Exchange

CMS

Dallas Area Providers

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Most Providers Won’t Build Their Own Gateway But Will Use an HIH 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) VendorA 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)

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An entity that provides services that enable providers or health organizations to exchange health information using the internet.

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HIHs that Plan to Offer esMD Services(starting in September 2011)

HealthIT+http://www.healthitplus.com

HealthPorthttp://www.healthport.com

IVANShttp://www.ivans.com

MROhttp://www.mrocorp.com

NaviNethttp://www.navinet.net/

RISARChttp://www.risarc.com

Exchange

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HIHs that Plan to Offer esMD Services in Nov 2011 or Jan 2012

Nov 2011• eSolutions (www.ecorpnet.com)

• Cobius (http://www.cobius.com)

• IOD, Inc. (http://www.iodincorporated.com)

• Proficient Health (http://proficienthealth.com)

• Craneware (http://craneware.com)

• MDClick (http://www.mdclick.com)

• Medical Electronic Attachment (http:// www.mea-fast.com)

• EHR Doctors (http://www.ehrdoctors.com)

Jan 2012• ECC Technologies (http://www.ecctec.com)

• Empowering Tech (www.empoweringapps.com)

• Invertex (http://ivertex.com)

• Stratice Heathcare(http://straticehealthcare.com)

• BACTES (http://bactes.com)

• GREENWAY (http://greenwaymedical.com)

• Secure Exchange Solutions (http://secureexsolutions.com)

• AKIRA (http://www.akira-tech.com)

• ApeniMED (http://www.apenimed.com)

• AT&T (www.att.com/healthcare)

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http://www.ecorpnet.com/�
http://www.cobius.com/�
http://www.iodincorporated.com/�
http://proficienthealth.com/�
http://craneware.com/�
http://www.mdclick.com/�
http://www.mea-fast.com/�
http://www.ehrdoctors.com/�
http://www.ecctec.com/�
http://www.empoweringapps.com/�
http://ivertex.com/�
http://straticehealthcare.com/�
http://bactes.com/�
http://greenwaymedical.com/�
http://secureexsolutions.com/�
http://www.akira-tech.com/�
http://www.apenimed.com/�
http://www.att.com/healthcare�
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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.

CMS Does Not Dictate How an HIH Communicates with Providers

http://directproject.org

http://wiki.directproject.org

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esMD HIHs:

Will receive no funding from CMS or ONC (Note: they may bill providers)

Attend calls with CMS (bi-weekly)

Build a CONNECT-Compatible Gateway

Obtain a certificate, IP address, and share key with CMS Gateway Contractor

Test with CMS Gateway Contractor Recruit providers to join “On-Board” to the Nationwide Health Information Network (April 2013)

• Sign Legal agreements (DURSAs)

• Test with ONC Gateway Team

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esMD Phase 1September 2011

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Gateway Built by

ECM Built by

ECM

CONNECTCompatible

Doc’ n RequestLetter PERM

Content Transport Services

CMS Private Network

PDF PDF PDF

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Imaged documents (PDF)

Important Metadata Fields:• Intended Recipient – Required Field• Claim ID – Required Field• NPI – Required Field• Case ID – Required If Known

A portion of a patient’s medical record in esMD format which will contain:

Definition of an esMD Package

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Detailed 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)

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esMD in Phase 2October 2012

Content Transport ServicesContent Transport Services

Structured Electronic Requests for Medical

Documentation

CONNECTCompatible

MACs PERM

CMS Private Network

ECM

xml PDF PDF

MedicareRecovery Auditors

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esMD in Phase 2January 2013

Exchange

Content Transport Services

Structured Electronic Requests for Medical

Documentation

CONNECTCompatible

MedicareRecovery Auditors MACs PERM

Private Network (CMSnet)

ECM

xml PDF PDF

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Current and Future Use Casesfor esMD

We Are Here Group 1 Documents

• Medical Documentation in XDR format (PDF)• Medical Documentation in X12 format (PDF)

Group 2 Documents• Structured Practitioner Orders• Structured Progress Notes• Structured ADMC (prior authorization) Requests

Group 3 Documents• esMD 2 enrollment

Group 4 Documents• Outbound ADRs (additional documentation requests)

Group 5 Documents• Request\Receive Documentation Status• Request\Receive Claim Status• Request\Receive Appeals Status

Group 6 Documents• All Administrative Transactions (i.e., Claims Submission, Claim Status, Eligibility lookup)• Coordination of benefits (Payer Pre & Post-Payment)• Refund Request• Medicare Bad Debt Reports (MCBD)• Other

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esMD Review ContractorsSeptember 2011*

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*These are anticipated dates and subject to change.Please check esMD website (http://www.cms.gov/ESMD)

• RAC A – Diversified Collection Services (DCS)• RAC B – CGI Technologies and Solutions• MAC J1 & J11 – Palmetto GBA• MAC J3 – Noridian Administrative Sevices• MAC J4 – Trailblazer Health Enterprises• MAC J5 – Wisconsin Physicians Services Health Insurance Corporation• MAC J9 – First Coast Service Options• MAC J12 – Highmark Medicare Services• MAC J13 - National Government Services• MAC J14 – NHIC• DME MAC A – NHIC• DME MAC B – NGS• DME MAC D – NAS• CERT – Livanta• PERM – A+Government Solutions

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esMD Review Contractors

November 2011*

• MAC J10 – Cahaba Government Benefit Administrators

• ZPIC 1 – Safeguard Services LLC

• ZPIC 7 - Safeguard Services LLC

• RAC D - HealthDataInsights

January 2012*

• MAC J15 – Cigna Government Services

• DME MAC C – Palmetto GBA

*These are anticipated dates and subject to change.Please check esMD website (http://www.cms.gov/esMD)

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esMD Review ContractorsSeptember 2011*• RAC A – Diversified Collection Services (DCS)

• RAC B – CGI Technologies and Solutions

• MAC J1 & J11 – Palmetto GBA

• MAC J3 – Noridian Administrative Sevices

• MAC J4 – Trailblazer Health Enterprises

• MAC J5 – Wisconsin Physicians Services Health Insurance Corporation

• MAC J9 – First Coast Service Options

• MAC J12 – Highmark Medicare Services

• MAC J13 - National Government Services

• MAC J14 – NHIC

• DME MAC A – NHIC

• DME MAC B – NGS

• DME MAC D – NAS

• CERT – Livanta

• PERM – A+Government Solutions

November 2011*• MAC J10 – Cahaba Government Benefit

Administrators

• ZPIC 1 – Safeguard Services LLC

• ZPIC 7 - Safeguard Services LLC

• RAC D - HealthDataInsights

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January 2012*

•MAC J15 – CIGNA Government Services

•DME MAC C – Palmetto GBA

*These are anticipated dates and subject to change.Please check esMD website (http://www.cms.gov/ESMD)

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In September 2011: • 300 Part A providers • 700 Part B providers

In December 2011:• 2000 Part A providers • 25,000 Part B providers

Estimate of Providers Submitting via esMD

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Exchange

Expanding esMD to other Review Entities

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MedicareRecovery Auditors PERM

CMS Private Network (also known as CMSnet)

Central Unit

Alabama Quality Improvement Organization

Content Transport Services

Medicare Secondary

Payer Review

Contractor(MSPRC)

Medicare Part D Review

Contractors (MEDICs)

Medicare Part C Review

Contractors (RADV)

Alaska Quality Improvement Organization

Arkansas Quality Improvement Organization

ECM

Medicare Administrative

Contractors

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For More Information

To contact anyone on the esMD Team:

[email protected]

CMS esMD Website:www.cms.gov/esMD

Follow Us on Twitter:@CMSGov (Look for #CMS_esMD)

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mailto:[email protected]�
http://www.cms.gov/esMD�
Page 26: esMD - Centers for Medicare & Medicaid Services

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