Have you ever found it difficult to obtain required documentation from a physician? In this interview with HME News, DME consultant Andrea Stark discuses several ways you can obtain the documentation you need without alienating your referral sources.

“It’s important to time it correctly so that you’re [requesting documentation] while the doctor still needs something from you” – Stark.

To see the full interview, visit: http://www.hmenews.com/video.php?cat_id=2&v_id=260.

A new pilot program, scheduled to begin in September 2011, will allow providers and suppliers to respond to documentation requests from most audit contractors electronically. Per CMS, the primary goal of Medicare’s Electronic Submission of Medical Documentation (esMD) pilot project is to reduce costs and cycle time by minimizing and eventually eliminating the mailing of paper documentation to medical review contractors.

The esMD program will be implemented in two phases. Beginning in September of this year, suppliers will have the option to respond to documentation request letters electronically. By 2012, CMS will expand esMD to allow review contractors to also send electronic documentation requests, rather than mailing paper letters.

Participation in the esMD program is completely voluntary. Physicians, hospitals and suppliers who wish to participate will need to obtain access to a special internet gateway, known as a CONNECT-compatible gateway, that meets the security standards established by the Nationwide Health Information Network (NHIN). Much like the network service vendors charged with providing connectivity to the CEDI gateway, suppliers will need to go through an authorized Health Information Handler (HIH) to obtain access to the esMD system. A total of 27 HIH’s will ultimately offer access to a CONNECT-compatible gateway; however, only the following 5 are expected to be ready to handle transmissions by September 2011: 

• HealthPort (http://www.healthport.com/)
• IVANS (http://www.ivans.com/)
• MRO (http://www.mrocorp.com/)
• NaviNet (http://www.navinet.net/)
• RISARC (http://www.risarc.com/)

Suppliers should take the following into consideration when deciding whether to participate in esMD:

1. Just like with the CEDI network vendors, the HIHs will likely charge suppliers a fee to submit documentation through their gateways. Fees are set independently by each HIH and are not regulated by CMS, so be sure to shop around.
2. The esMD system will only accept documents in a portable document format (PDF). Paper documents will need to be scanned and converted into PDF files before being transmitted. If you have an electronic health record system or program that is able to export information in PDF format, such as Adobe Acrobat, this should not be an issue. Also, some HIHs may also offer scanning and conversion services in addition to their esMD services.
3. Not all audit contractors are accepting electronic submissions at this time. While all DME MACs are expected to eventually participate, not all RAC and ZPIC contractors have jumped on board. Suppliers who do not wish to participate in esMD or who are submitting responses to non-participating medical review contractors may continue to mail or fax documentation for review.

Medical review contractors planning to participate in the esMD program and accept electronic submissions include:

Beginning September 2011:

• The CERT Contractor
• RAC A (DCS)
• RAC B (CGI)
• DME MAC A (NHIC)
• DME MAC D (NAS)

Beginning November 2011:

• RAC D (HelathDataInsights)
• DME MAC B (NGS)
• ZPIC for  Zones 1 and 7 (SafeGaurd Services)

Beginning January 2012:

• DME MAC C (CGS)

Although the Jurisdiction C RAC (Connolly Healthcare) has not confirmed participation in esMD, CMS expects the RAC to begin accepting electronic transactions within the next 12 months. At this time, there is no word on whether the remaining ZPIC contractors will participate.

For more information, including a complete list of providers who plan to offer esMD gateway access, visit: http://www.cms.gov/esMD and http://www.qssinc.com/esmd.

In testimony given by Inspector General Daniel Levinson to members of the House of Representatives on March 17, 2011, the OIG announced that they will be performing, among other things, a review of improper payments identified by CERT contractors. Specifically, the OIG plans to:

• Review the amount of improper payments that have subsequently been overturned on appeal.
• Develop a pilot project to obtain missing documentation identified during CERT reviews.
• Perform an independent medical review of claims to determine whether Payment Error Rate Management (PERM) contractors are working within PERM guidelines (applies to Medicaid and Children’s Health).

This testimony follows CMS’ announcement that they will be performing follow-up reviews on the CERT contractor to specifically re-examine claims that were previously cited with errors (see below) and is a sign that officials within the industry may be taking notice of the disconnects between auditing contractors finding high instances of “errors” and the number of “errors” that are subsequently overturned in the supplier’s favor.

However, suppliers can expect little relief in the way of reviews from the OIG itself. Products currently under review for documentation requirements and improper payments include power wheelchairs and lower limb prostheses. Depending on the findings, the OIG may recommend CMS and the DME MACs implement additional edits or medical reviews for these product categories, resulting in increased pre-pay and/or post-pay reviews.

The Inspector General’s complete testimony may be read at: http://oig.hhs.gov/testimony/docs/2011/levinson_testimony_03172011.pdf.