Information Concerning Medicare Review Contractors

on Tuesday, 22 March 2011. All News Items

Use of Claims History Information in Claim Payment Determinations

CMS recently updated section 3.18 of the Program Integrity Manual regarding the use of claims history information in claim payment determinations by Medicare Administrative Contractors (MACs), Comprehensive Error Rate Testing (CERT) contractors and Recovery Audit Contractors (RACs). Although Medicare contractors shall not generally use claims history to make payment determinations, the policy details some circumstances where claims history can be used as a supplement to medical record documentation in making a payment determination. These exceptions include:

  • To identify other providers who may have documentation to support payment of a claim;
  • To document an event that supports the need for a service or item billed; and
  • To determine or verify frequency, quantity, duplication and overutilization of services.

Note that Medicare reviewers may use claims history for other purposes such as data mining. For more information and examples, see Transmittal 367.

Electronic Submission of Medical Documentation (esMD)

Currently most Medicare Review Contractors request documentation by sending a paper letter to the provider and providers submit records by mail or fax. A new CMS pilot will give providers a new mechanism for submitting medical documentation – the Electronic Submission of Medical Documentation (esMD).

During Phase I of esMD, which is scheduled to go live in July 2011, providers have the option to submit medical documentation electronically. Review Contractors that plan to accept electronic medical documentation are listed on the CMS esMD website and include the Medicare Administrative Contractor for Jurisdiction 10 (Cahaba GBA), Comprehensive Error Rate Testing (CERT) contractor, and Payment Error Rate Measurement (PERM) contractor. The Recovery Audit Contractor (RAC) for Region C, which includes Alabama, is on the list of reviewers who plan to begin accepting electronic submissions by December 2011. Phase II of esMD is scheduled to go-live in 2012 and will involve the electronic receipt of medical record request from the Review Contractors.

The Information for Providers section of the website includes the following information:

  • “The esMD allows for the submission of PDF or TIFF files. Therefore, any EHR system that is capable of exporting health information as a PDF or TIFF file can be submitted via an esMD gateway.”
  • “In order to send medical documentation electronically to Medicare Review Contractors, providers (physicians, hospitals, etc.) must obtain access to a CONNECT-compatible gateway. Although some large providers, such as hospital chains, may choose to build their own gateway, CMS anticipates that many providers will choose to obtain gateway services by entering into contract or other arrangement with a Health Information Handler (HIH) that offers esMD gateway services.”

The site also notes that participation is voluntary; providers may continue to submit records by mail or fax if they wish.

Complete information regarding esMD can be found at http://www.cms.gov/ESMD/ . There are also several CMS Frequently Asked Questions (FAQs) concerning esMD at https://questions.cms.hhs.gov/app/answers/list

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