Medicare Electronic Submission of Medical Documentation Pilot Program Begins September 2011

As many already know, when a review contractor (e.g., Recovery Audit Contractors (“RACs”), Medicare Administrative Contractors (“MACs”), the Comprehensive Error Rate Testing (“CERT”) contractor, the Program Error Rate Measurement (“PERM”) contractor, and Zone Program Integrity Contractors (“ZPIC”)) identifies an improper payment, the review contractor requests medical documentation from the provider or supplier to ensure the claim and supporting documentation comply with the Medicare reimbursement rules. This request is typically in the form of a paper letter to the provider or supplier wherein the provider or supplier may only submit the requested records by mail or fax.

However, recently, the Centers for Medicare and Medicaid Services (“CMS”) began conducting a pilot program–the Electronic Submission of Medical Documentation (“esMD”) pilot–which allows providers and suppliers to send their records to review contractors electronically. According to an MLN Matters article regarding the new esMD pilot program, “[t]he primary intent of esMD is to reduce provider costs and cycle time by minimizing and eventually eliminating paper processing and mailing of medical documentation to review contractors. A secondary goal of esMD is to reduce costs and time at review contractors.” Provider and supplier participation in esMD is completely voluntary and submission of paper and/or fax documentation continues to be acceptable.

This pilot program will be conducted in two phases. During Phase 1, beginning September 15, 2011, review contractors will continue to send paper requests for medical documentation and providers or suppliers will have the option to send the medical documentation electronically in portable document format (“PDF”). During Phase 2, beginning October 2012, review contractors will send electronic requests for medical documentation. CMS provides the following graphics depicting the simplified relationship between the review contractors and the provider at each phase:

Providers and suppliers wanting to begin submitting their medical documentation via esMD must obtain access to a CONNECT-compatible getaway. A CONNECT-compatible gateway is the medium through which medical documentation can be exchanged using Nationwide Health Information Network specifications and standards that allow for the secure and private exchange of health information over the Internet. Providers and suppliers looking for CONNECT-compatible gateways may look to Health Information Handlers (“HIHs”)–companies that handle health information on a provider or supplier’s behalf. A list of HIHs that offer esMD gateway services is provided in the MLN Matters article linked above or on CMS’ esMD page.

CMS provides the following more detailed graphics depicting Phases 1 and 2 in their entirety:

Phase 1:

Phase 2:

CMS also provided a timeline for Phase 1 when some review contractors will be scheduled to accept esMD transactions:

Note: CMS expects that the Region C and D RACs and the remaining MACs will begin accepting esMD transactions within the next twelve (12) months.

For more information on esMD, review contractors, audits or compliance, please contact Abby Pendleton, Esq. or Jessica L. Gustafson, Esq. at (248) 996-8510 or (212) 734-0128 or visit the HLP website.