Nearly 500,000 medical records have been sent to Medicare review contractors through the Centers for Medicare & Medicaid Services’ (CMS) Electronic Submission of Medical Documentation (esMD) system, since it launched in 2011.
The system enables providers to send medical documentation to review contractors electronically. Review contractors find improper payments and potential fraud by reviewing a sample of claims. They request medical documentation from the provider or supplier, and manually review the claims against the medical documentation to verify the providers' compliance with Medicare's rules.
According to CMS’ annual report, prior to 2011, hospitals, physicians, and other medical providers sent medical records via mail or fax to the requesting review contractor. Providers often criticized the paper-based process as being costly and time consuming. Many providers, especially those who use electronic health records (EHRs), requested an electronic means to respond to these documentation requests, the report said.
More than 30,000 Medicare providers were using the system—which is based on standards developed by the Office of the National Coordinator for Health IT (ONC)—as of Sept. 30, 2013. To access the esMD system, providers can either build their own gateway that will connect to the CMS esMD Gateway, or contract with a CMS-certified health information handler (HIH). As of Sept. 30, no providers had chosen to build their own gateway.
While esMD is not mandatory, many healthcare providers find that it reduces cost and increases efficiencies, the report found. In order to address provider concerns, CMS has instructed review contractors not to target providers for medical review based on their use of esMD.
In September 2012, CMS implemented a prior authorization (PA) process via the esMD Gateway for power mobility devices for FFS Medicare beneficiaries who reside in seven states with high populations of error prone providers. In January 2013, CMS expanded the esMD Gateway to allow durable medical equipment suppliers and providers to send electronic PA requests to Medicare review contractors. And in June, CMS enabled automated PA review results responses from Medicare review contractors to HIHs via the esMD Gateway.