2. Helpful Information

                Electronic Submission of Medical Documentation (esMD) 

                Background  

                The primary goals of Provider Compliance Group in Center for Program Integrity office of the Centers for Medicare & Medicaid Services (CMS)  are:

                1. Reducing Improper Payments (saving Medicare Trust Fund)

                2. Minimizing Appeals for denied claims (cost savings)

                3. Administrative Simplification (reduce paperwork)

                4. Reducing Provider Burden

                In the fiscal year (FY) 2016, improper payments under the Medicare fee-for-service totaled $41.08 billion, (i.e. 11 percent of all payments made). Errors contributing to improper payments can be categorized into four areas – no documentation, insufficient documentation, failing medical necessity and incorrect coding. CMS employs several types of Medicare Review Contractors (RCs) to measure, prevent, identify, and correct improper payments or find potential fraud. These RCs request medical documentation from the providers who submitted the claims, and review the claims against the medical documentation to verify the providers’ compliance with Medicare rules.

                esMD Gateway 

                Currently, RCs request approximately 2 million medical documents per year by mailing a paper request letter via US Postal Service to Medicare providers and suppliers. The responses with medical documentation corresponding to the medical requests are traditionally submitted to CMS by providers or suppliers via mail or fax which is expensive and inefficient. On September 15, 2011, the CMS implemented the Electronic Submission of Medical Documentation (esMD) system as an additional option for providers using their respective certified Health Information Handlers (HIHs) to send medical documentation to the RCs electronically. esMD system transactions are safe and secure since it uses exchange gateway standards developed by the Office of the National Coordinator for Health Information Technology. In order to securely exchange electronic private health information, robust ‘Gateways’ are built on the sender and receiver ends. The CMS esMD Gateway is built using the open source CONNECT software.

                For more information please visit esMD website at  http://go.cms.gov/esMD

                Current Status 

                esMD growth has reached to network with 30 RCs and 17 HIHs representing more than 130,000 Medicare providers exchanging more than 3.5 million transactions in total from inception. esMD has expanded to support multiple Lines of Business including,

                • for providers/HIHs to send Prior Authorization Request, Appeal Request, Determination of Coverage Request, and RC Discussion Request

                • for RCs to send Prior Authorization Response, Electronic Medical Documentation Request, Additional Documentation Request letter or eMDR review results

                CMS plans to add more esMD services in the future releases such as, secure exchange of decision letters, unsolicited documentation and support for exchange of structured documentation.