Medicare Pilots Project for esMD

Each year, the Medicare Fee-For-Service (FFS) Program makes billions of dollars in estimated improper payments. The Centers for Medicare & Medicaid Services (CMS) employs several types of Medicare review contractors to measure, prevent, identify, and correct these improper payments. Review contractors find the improper payments by requesting medical documentation from each provider who submitted a questionable claim. The review contractor then manually reviews the claims against the submitted medical documentation to verify the providers’ compliance with Medicare’s rules.

Currently, review contractors request medical documentation by sending a paper letter to the provider. The provider has two options for submitting the requested records: 1) mail paper, or 2) send a fax.

What You Need to Know

Medicare’s Electronic Submission of Medical Documentation (esMD) pilot project gives some providers a new mechanism for submitting medical documentation to review contractors. A list of review contractors that will accept esMD transactions can be found on the Internet.

The esMD pilot will begin in September 2011.

The 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. To send medical documentation electronically to review contractors, Medicare providers (including physicians, hospitals, and suppliers) must obtain access to a CONNECT-compatible gateway.

  • Certain larger providers, such as hospital chains, may choose to build their own gateway.
  • Many providers may choose to obtain gateway services by entering into a contract or other arrangement with a health information handler (HIH) that offers esMD gateway services.

A list of HIHs that offer esMD services as of September 2011 can be found in the “Key Points” section of this article. An updated listing of the HIHs that have been approved by CMS to offer esMD services can also be found on the Internet. CMS does not set the price that an HIH may charge a provider for esMD services. Providers who believe it may be more efficient to respond to documentation requests electronically are encouraged to contact one or more of the HIHs to determine if esMD services are available at a reasonable price.

What You Need to Do

You should know that esMD is completely voluntary. You may continue to mail or fax documentation to your review contractor.

The initial esMD system accepts PDF files, which means that even those providers who have paper records may utilize esMD services as long as there is a mechanism to scan the paper records into PDF files. Some HIHs may offer scanning services in addition to their esMD services.

Source: Special Edition (SE) MLN Matters® SE1110. The SE affects all Medicare FFS providers who submit medical documentation to Medicare review contractors.

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