By George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law
Medicare providers are now able to submit medical documents to the Centers for Medicare & Medicaid Services (CMS) review contractors electronically for almost all of them. This includes the Medicare Administrative Contractors (MACs), Recovery Audit Contractors (RACs) and will soon include several Zone Program Integrity Contractors (ZPICs).
For a list of review contractors currently accepting electronic records, click here.
CMS makes agreements with review contractors to identify and correct improper Medicare payments made to providers. Review contractors find the improper payments by selecting a small sample of claims and requesting medical documentation from the provider who submitted the claims. The review contractor then manually reviews the claims made against the medical documentation provided to verify the providers' compliance with Medicare's rules.
Medicare Providers Can Submit Medical Records to a Number of Review Contractors Electronically.
Currently, review contractors request medical documentation by sending a letter to the provider. These providers previously had two options for submitting the requested records:
1. Mail a hard copy of the records or
2. Fax the records.
Now, providers can submit medical records electronically to participating review contractors. CMS calls this new mechanism the Electronic Submission of Medical Documentation (esMD) program. For a chart illustrating how esMD words, click here.
Phase 1 of esMD Launched on September 15, 2011.
Phase 1 of the esMD program was initiated on September 15, 2011. During Phase 1 of esMD, Medicare providers still receive medical documentation requests via a letter in the mail. However, they have the option to electronically send medical records to the requesting review contractor.
During Phase 2 of esMD, providers will receive requests when their claims are selected for review electronically. CMS plans to initiate Phase 2 in the future but no specific date has been announced.
First Coast Service Options, Inc. Approved for Phase 1 of esMD.
Florida's Medicare Administrative Contractor (MAC), First Coast Service Options, Inc. (First Coast) has been approved by CMS to participate in Phase 1 of esMD. Florida Medicare providers who have been asked to submit records for review to First Coast can now submit them electronically.
Other review contractors who have been approved to participate in Phase 1 of esMD through May 2012 include:
- Region A Medicare Recovery Audit (Diversified Collection Services, Inc. or "DCS")
- Region B Medicare Recovery Audit (CGI Technologies and Solutions, Inc. or "CGI")
- Medicare Administrative J1 (Palmetto GBA)
- Medicare Administrative JF (J2 & J3) (Noridan)
- Medicare Administrative J4 (Trailblazer)
- Medicare Administrative J5 (Wisconsin Physicians Service or "WPS")
- Medicare Administrative J9 (First Coast Service Options Inc. "FCSO")
- Medicare Administrative J11 (Palmetto GBA)
- Medicare Administrative J12 (Novitas Solutions)
- Medicare Administrative J14 (NHIC, Corp. or "NHIC")
- Comprehensive Error Rate Testing (CERT) Contractor
- Program Error Rate Measurement (PERM) Contractor
- DME Medicare Administrative JA (NHIC, Corp. or "NHIC")
- DME Medicare Administrative JD (Noridian)
- Medicare Administrative J13 (National Government Services or "NGS")
- DME Medicare Administrative JB (National Government Services or "NGS")
- Medicare Administrative J10 (Cahaba)
- Region D Medicare Recovery Audit (Health Data Insights or "HDI")
- Medicare Administrative J15 (CGS Administrators, LLC or "CGS")
- DME Medicare Administrative JC (CGS Administrators, LLC or "CGS")
- Region C Medicare Recovery Auditor (Connolly).
Several of the ZPICs are planning on participating in the esMD program starting summer 2012. These include:
- ZPIC Zone 1 (SafeGuard Services LLC or "SGS")
- ZPIC Zone 7 (SafeGuard Services LLC or "SGS").
Providers Not Required to Submit Medical Records Electronically.
Medicare providers do not have to submit medical documentation electronically. The esMD program is completely voluntary.
If providers do want to participate in the esMD program, they must first find out if their review contractor accepst esMD transactions. Additionally, providers will have to obtain access to an esMD gateway. To obtain access to a gateway, providers can either build their own or hire a Health Information Handler (HIH) to construct the gateway system. To find out which HIHs offer esMD gateway services to providers, click here. To learn more about requirements for participating in the esMD program, click here.
Contact Health Law Attorneys Experienced with Medicare and Medicaid Audits.
The Health Law Firm's attorneys routinely represent physicians, medical groups, clinics, pharmacies, durable medical equipment (DME) suppliers, home health agencies, nursing homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions. They also represent health providers in preparing and submitting corrective action plans (CAPs), requests for reconsideration, and appeal hearings, including Medicare administrative hearings before an administrative law judge.
To contact The Health Law Firm, please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.
Centers for Medicare & Medicaid Services. "Electronic Submission of Medical Documentation." Centers for Medicare & Medicaid Services. (Apr. 9, 2012). From:
About the Author: George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.
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