ELECTRONIC AUDIT DOCUMENTATION FOR RACS AND MACS. RAC SUMMIT November 9, 2011

Transcription

1 ELECTRONIC AUDIT DOCUMENTATION FOR RACS AND MACS RAC SUMMIT November 9, 2011

2 Overview: Electronic Document Submission for Medicare Audits Today s Agenda Background on Improper Payments Medical Documentation Process CMS esmd Program IVANS AuditDocs Solution Medicare Administrative Contractor (MAC) Perspective Current and Future Use Cases for esmd If you experience any technical difficulties during the webinar, please call

3 IVANS Develops Industry-Focused Managed Services Privately-held stock corporation Headquartered in Stamford, CT with offices in Tampa, FL & Cincinnati, OH Owned today by 30 insurance companies and IVANS employees/directors Governed by an independent board of directors Sophisticated Network & Data Solutions Deep Domain Expertise Successful managed services business for 25+ years Serve Healthcare, Property-Casualty, Retail, Manufacturing, Business Services Particular expertise in one-to-many/many-tomany communications Industry-Focused Solutions 3

4 IVANS is Focused on Making Data Exchange Accessible to the Broader Provider and Payer Population IVANS enables the secure exchange of healthcare information between providers, and thousands of health insurers and government entities. Using IVANS industry experience and proven technology, practitioners and patients have the necessary tools to make sound healthcare decisions. 14

5 Background about Improper Payments Medicare receives 4.8 M claims per day CMS Office of Financial Management estimates that each year: The Medicare FFS program issues more than $34.3 B in improper payments (error rate 2010: 10.5%). The Medicaid FFS program issues more than $22. 5 B in improper payments (3-year rolling error rate: 9.4%). Most improper payments can only be detected by a human comparing: a claim to the medical documentation 5

6 Background about Medical Documentation Requests Medical Documentation Requests are sent by: Medicare Administrative Contractors (MACs) Comprehensive Error Rate Testing Contractor (CERT) Payment Error Rate Measurement Contractor (PERM) Medicare Recovery Auditors (formerly called RACs) Claim review contractors issue over 2 million requests for medical documentation each year. Claim review contractors currently receive most medical documentation in paper form or via fax. Claim review contractors currently receive a tiny number of imaged documents in CD/DVD form. 6

7 Today s Medical Documentation Process Doc n Request Letter Review Contractor Paper Medical Record Provider 4

8 Solution: Electronic Submission of Medical Documentation (esmd) Phase 1: Doc n Request Letter Live September 15 electronic Phase 2: electronic Live Fall 2012 electronic 5

9 esmd is NOT mandatory CMS recognizes that not all providers are adopting HIT solutions at the same pace Late Adopter Still using paper records. Intends to rely on fax machines, USPS, FedEx, etc. for the for the next 10 years. Average Adopter Using imaged & electronic records. Will wait to see which esmd Service Providers emerge in their area (and at what price). Early Adopter Has used EHRs for years. Ready for esmd now! 9

10 The Nationwide Health Information Network Set of standards, protocols, legal agreements, and specifications that a consortium of health information organizations have agreed are necessary for secure and private exchange of health information over the public internet. Overseen by the Office of the National Coordinator for Health IT (ONC) Comprised of two parts: Direct designed for an individual to individual submission of health information Exchange designed for computer to computer exchange of health information =CommunityPage&parentid=8&mode=2&in_hi_userid=11113&cached=true 10

11 CMS esmd Gateway CMS has built an Exchange Gateway to accept esmd transactions from providers. The CMS esmd gateway went live in September CMS uses the CONNECT brand of gateway Exchange 8

12 Estimate of Providers Submitting via esmd In September 2011: 300 Part A providers 700 Part B providers In December 2011: 4000 Part A providers 14,000 Part B providers 9

13 Most Providers Won t Build Their Own Gateway But Will Use an HIH to Provide Gateway Services A Health Information Handler (HIH) is any company that handles health information on behalf of a provider: (1)Health Information Exchange (HIE)/Regional Health Information Organization (RHIO) (2)Release of Information (ROI) Vendor A company that manages the release of information for providers. Their services may include logging and tracking the request, retrieving the patient record from multiple locations in multiple formats, identifying the information needed to fulfill the request, requesting additional authorization, if needed, copying, packaging and mailing, and invoicing. (3)Electronic Health Record (EHR) Vendor (4)Claim Clearinghouse (5)Health Internet Service Provider (HISP) An entity that providers services that enable providers or health organizations to exchange health information using the internet. 13

14 IVANS AuditDocs 11

15 IVANS is one of the first Health Information Handlers able to handle esmd transactions for any provider Solution IVANS AuditDocs allows providers to send the documentation electronically to review contractors though the IVANS LIME Portal AuditDocs is the IVANS-branded product built to communicate with the Electronic Submission of Medical Documentation (esmd) gateway Larger providers Interface layer Smaller providers LIME portal IVANS HIE Platform IVANS AuditDocs 15

16 IVANS Health Information Exchange supports the transferring of administrative and clinical information Outgoing Admin Info Eligibility request Claims submission Outgoing Clinical Info Clinical information Referrals Hospital Medical Practice Skilled Nursing Home Health Hospice DME Clinic Lab/Radiology EMR Provider I Connect technology adopted for NHIN gateway Government Payers Commercial Provider II Hospital MedicalP ractice Skilled Nursing Home Health Hospice DME Clinic Lab/Radiology EMR Incoming Admin Info Eligibility verification Claims confirmation Claims status Electronic remittance Incoming Clinical Info Clinical information Referrals IVANS Health Information Exchange Platform 16

17 IVANS AuditDocs: Phase 1 September 2011 Medical record requests are sent to providers through the mail, responses are returned to Review Contractors electronically Providers upload files into the IVANS AuditDocs application, files then sent securely to Review Contractor using NHIN standards 16

18 IVANS AuditDocs: Phase 2 Fall 2012 Review Contractor Connect Gateway IVANS AuditDoc s Internet Provider The process is now fully automated with IVANS operating as a Health Information Exchange (HIE) Medical record requests are sent to providers electronically, responses are returned to Review Contractors electronically 17

19 Which Review Contractor Accepts esmd Transactions? 1. RAC Recovery Audit Contractor 2. MAC Medicare Administrative Contractor 3. CERT Comprehensive Error Rate Testing program 4. PERM Payment Error Rate Measurement program 5. ZPIC Zone Program Integrity Contractor Review Contractors participating in esmd at Go-Live (September 15, 2011) Review Contractors participating in esmd (end of September) Review Contractors participating in esmd (November 2011) Review Contractors participating in esmd (January 2012) RAC A RAC B MAC J1 MAC J3 MAC J4 MAC J5 MAC J9 MAC J11 MAC J14 DME MAC A DME MAC D Comprehensive Error Rate Testing Contractor (CERT) Program Error Rate Measurement Contractor (PERM) MAC J12 RAC D MAC J10 MAC J13 ZPICs (Zone 1 & 7) DME MAC B MAC J15 DME MAC C 19

20 Current and Future Use Cases for esmd We are here Group 1 Documents Group 2 Documents Group 3 Documents Group 4 Documents Group 5 Documents Group 6 Documents Medical Documentation in XDR format (PDF) Medical Documentation in X12 format (PDF) Structured Practitioner Orders Structured Progress Notes Structured ADMC (prior authorization) Request esmd 2 enrollment Outbound ADRs (additional documentation requests) Request\Receive Documentation Status Request\Receive Claim Status Request\Receive Appeals Status All Administrative Transactions (i.e., Claims Submission, Claim Status, Eligibility lookup) Coordination of benefits (Payer Pre & Post-Payment) Refund Request Medicare Bad Debt Reports (MCBD) Other 20

21 National Government Services: Medicare Administrative Contractor (MAC) Perspective National Government Services has tested and is ready to support onboarding Providers esmd Process is parallel to our paper process today esmd Process benefits for providers include: Improve tracking of medical record submission Reduced staff and mail time allowing providers to review before submitting records Reduce denials for untimely submission of records National Government Services plans to use esmd gateway for more than RAC Audits TPL for home health as example Level 1 Appeals Medical Reviews 21

22 In Summary 1. Determine if your review contractor can accept esmd transactions 2. Get connected to a gateway A list of Health Information Handlers can be found at the CMS esmd website IVANS can get you connected immediately whether you are processing audits for Medicare or commercial payers 22

23 For More Information CMS esmd Website: Learn about IVANS CONNECT Website: IVANS AuditDocs Follow Us on IVANS HealthWire Blog 23

24 Thank You Questions From the Audience 24