Medicare Online Documentation System To Cut Healthcare Costs

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Healthcare providers will have a new, less expensive way to send documents to Medicare review contractors starting in August. Instead of faxing or mailing documents requested to support claims, they will be able to transmit them online through an approved third party to the Centers for Medicare and Medicaid Services (CMS), which will forward them to the appropriate review contractor.

CMS' electronic submission of medical documents (esMD) pilot appears to be one of the first programs to incentivize private-sector entities to use its open source CONNECT software, which links information systems to the National Health Information Network. To act as a conduit between healthcare providers and CMS, a private company must offer secure messaging through the CONNECT gateway.

Seven health information handlers (HIHs) are expected to participate in the esMD pilot. The best known of these firms is NaviNet, which provides Web-based connectivity between providers and payers, including Medicare carriers. Eleven other companies--including AT&T and EHR vendor Greenway--have applied to become HIHs.

CMS estimates that this fall, 336 hospitals and 749 physicians will submit electronic documentation through an esMD health information handler. The agency says it expects the number of providers to grow "dramatically" in 2012 and 2013, indicating that this is a pilot only in the sense that it's starting small.

CMS will accept only unstructured documents such as PDFs in the first phase of the esMD pilot. Later, it will expand that to include structured documents generated by electronic health records. There are no plans to require hospitals and physicians to send document attachments online.

"The primary intent of the esMD program is to reduce provider costs and administrative costs by minimizing paper processing and mailing of medical documentation to Medicare and Medicaid review contractors," said CMS spokesman Joseph Kuchler. "A secondary goal is to reduce costs and time at the review contractors."

Among the review contractors currently participating in the esMD program are Medicare Recovery Auditors, Medicare Administrator Contractors (MACs), the Comprehensive Error Rate Testing Contractor (CERT), and the Program Error Rate Contractor (PERM). In the future, CMS expects that Zone Program Integrity Contractor (ZPICs) and other review organizations will accept esMD transactions.

During phase 1 of esMD, the review contractors will continue to mail requests to providers. In phase 2, they will email the requests.

NaviNet will use its new Doc Xchange software to send provider documentation to CMS through the CONNECT gateway. Initially, Doc Xchange will be available only through NaviNet Insurer Connect, which the company says is the industry's leading multi-payer portal. Later, NaviNet will begin to integrate the esMD capability directly into EHRs, starting with its own application, said Laurance Stuntz, the company's senior VP of application integration.

NaviNet research shows that medical offices may spend up to $12 and hospitals up to $30 for each document they have to fax or mail. Transmitting the information online, Stuntz said, can cut that cost in half. He estimated that a typical physician practice could save $100 per provider, per month by sending documents online to CMS.

These document requests, he added, are not just related to audits. Review contractors might want to see claims documentation for a variety of reasons.

NaviNet plans to expand Doc XChange to facilitate document exchanges between providers and commercial payers, plus doctor-to-doctor exchanges for referral purposes, Stuntz noted. It should be relatively easy, he said, for health plans to accept documents using the CONNECT protocol, since it doesn't require them to change their database structures.

The Health Insurance Portability and Accountability Act (HIPAA) transaction protocol covering document attachments has never been finalized, and other parts of the HIPAA 4010 transaction set that was introduced a few years ago have also proved problematic for payers, Stuntz noted. But when CMS begins accepting structured documents in the esMD program, he said, it will likely use the HIPAA transaction for document attachments.

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