While the industry awaits the American Hospital Association’s RACTrac Survey for the second quarter of 2012, three things are being heard from healthcare providers:

  • More audits are being conducted.
  • More records are being requested.
  • Fewer dollars are being recouped.

It’s true, the Centers for Medicare & Medicaid Services (CMS) continues to ask for more medical records and recently increased the limit on the number of cases RACs can request every 45 days. However, auditors are finding fewer and fewer issues. The process is leading providers to ask, “Is the administrative burden of preparing records, conducting audits and engaging in appeals worthwhile?”

It’s an interesting question, and one we hope CMS will address later this year. In the interim, CMS is taking significant steps to reduce costs and labor requirements in one area: record submission. Launched in 2011, CMS’s Electronic Submission of Medical Documentation (esMD) program is making progress and gaining fans.

Electronic Submission Makes Headway

Providers expressed many concerns about esMD when it first was introduced. However, recent data reveals that the system is secure, working properly and being used more frequently than ever.

The system allows providers audited by RACs, MACs, PERM, CERT and/or ZPICs to transmit requested documents electronically over the Internet using secure Nationwide Health Information Network (NHIN) protocol. Providers electronically submit auditor-requested documents to an official Health Information Handler (HIH) that has an established esMD gateway. Providers also can establish their own esMD gateways for record submission.

HealthPort is one of these “handlers” and currently is preparing for esMD transmission and implementing failsafe procedures prior to going live.

Fears Alleviated

Initial fears that esMD would make audits easier for the RACs have been alleviated. In fact, most of esMD’s benefits apply to providers. In summary, it:

  • Eliminates Federal Express costs.
  • Increases the amount of revenue eligible to be retained per case (the limit recently was capped at $25 per case).
  • Takes paper out of the record submission process.
  • Helps providers meet timelines.
  • Reduces risks of technical denials.

Perhaps most importantly for providers, there is no documented positive or negative impact -0 on appeal success when using esMD. The next step will be sending electronic record requests via the gateway. But again, auditors must remain within CMS’s published case limits.

Technology and Process Changes

Of course, the use of esMD over Federal Express shipment of paper medical record copies does require some technology and process changes on the part of the provider. But these changes are all for the better and will result in the improvements noted above.

To avoid pitfalls, providers should centralize their audit processing across all locations in their organization, if at all possible. Backup procedures and processes should be in place just in case the network is temporarily down.

In addition, providers should continue to confirm delivery even though the confirmation will be in a different form. There also should be backup plans in place just in case confirmation is not received in the specified time frames. Providers will need to decide in these cases if they will attempt to submit through esMD again or revert to FedEx or other paper-based delivery methods.

Finally, some HIHs have direct electronic connections to the auditing bodies. Providers should be diligent in understanding how each HIH will communicate with all the various auditing entities.

Year of Advance

While providers still can opt for manual, paper mailing processes, the use of a HIH alongside electronic submission via the esMD gateway is more economical and less labor-intensive. Now proven safe and secure, we expect 2012 to be year of its advance.

About the Author

Lori Brocato, HealthPort Audit Product Manager, has over 16 years of experience in the healthcare technology industry creating product lifecycle plans and executing product strategies. Ms. Brocato frequently serves as an audit expert sharing audit management trends and best practice guidelines as a regular presenter for industry events and webinars.  She is the author of HealthPort’s audit Insights Blog and provides expert input for many trade publication articles each year. Ms.Brocato holds the distinction of being RAC-certified by the Medicare RAC Summit and is a member HIMSS, HFMA, and AHIMA.

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