Improving Workflow and Increasing Efficiencies with the CMS esmd Electronic Solution March 3, 2016

Transcription

1 Improving Workflow and Increasing Efficiencies with the CMS esmd Electronic Solution March 3, 2016 Joyce Ann Davis, MSIT, COR III, Lieutenant Commander, United States Public Health Service Deputy Director Rudy Braccili, Jr. MBA, AAHAM-CRCE, Executive Director, Revenue Cycle Services/Boca Raton Regional Hospital

2 Session presenters Joyce, Davis -- Deputy Director, Division of Division of Compliance Projects and Demonstrations Rudy Braccili, Jr., MBA, AAHAM-CRCE -- Executive Director, Revenue Cycle Services/Boca Raton Regional Hospital

3 Conflict of Interest Joyce Davis Has no real or apparent conflicts of interest to report. Rudy Braccili, Jr., MBA, AAHAM-CRCE Has no real or apparent conflicts of interest to report.

4 Agenda Introduction to and mission of Electronic Submission of Medical Documentation (esmd) program esmd purpose and background Exchanging information: explaining the role of esmd The role of Health Information Handlers Results achieved: One health system s story

5 Learning Objectives Define the mission of the esmd program Describe the reason for the creation of esmd Identify the impact of esmd on hospitals Recognize how to navigate esmd for the best outcomes

6 esmd Benefits Realized esmd Has Helped Boca Raton Regional Hospital Save More Than $4 Million esmd Reduces Labor and Supply Costs, Increasing Net Revenue Electronic exchange claim attachments reduces denials; eliminates paper processes, reduces claim turn around time and net A/R days

7 CMS esmd Program Origin of CMS esmd program Application and impact to health systems Current phase and program status Most improper payments can only be detected by a human comparing a claim to the medical documentation; claim review contractors currently receive most medical documentation in paper form or via fax esmd background

8 Polling question: esmd is required to electronically exchange claims data. 1. True 2. False

9 esmd Background Request Letter Provider Before esmd: Review Contractor Paper Medical Record Healthcare payers frequently request that providers submit medical documentation to support a specific claim(s). Until recently, this has been an entirely paper process and has proven to be burdensome because of the time, resources and cost to support a paper system. Phase 1: Doc n Request Letter electronic The ONC S&I Framework Electronic Submission of Medical Documentation (esmd) initiative has developed implementation guides to support an entirely electronic documentation request. Phase 2: electronic electronic

10 esmd Goals 1. Reduce improper payment through prior-authorization and encourage better documentation 2. Minimize provider burden through electronic communication of medical information (esmd) to create structured data to facilitate review process and include digital signatures to establish data integrity and provenance 3. Adopt/promote standards to facilitate electronic information exchange

11 Benefits of esmd Quicker turnaround: Providers have reported the payment turnaround when using esmd is six days as opposed to the paper process which is approximately three weeks. Reduced labor costs: esmd helps to reduce the amount of labor required to fulfill these requests by no longer having to print and mail paper, feed a fax machine or copy data to portable media (CDs, DVDs, etc.) Reduced hard costs: esmd can also reduce hard costs like shipping and handling expenses.

12 esmd Realities The Electronic Submission of Medical Documentation (esmd) program provides a more efficient, secure means of delivering medical records to the requesting contractor esmd leverages the standards required by the ehealth Exchange, and the open-source technology called CONNECT for communication gateways, to keep the documentation secure as it moves from the provider to the requesting contractor The esmd program addresses information exchange and endorses the use of exchange through certified Health Information Handlers (HIH) to reduce reliance on manual processes esmd is finding allies on each side of the aisle even if the overall Recovery Audit Contractor program remains contentious

13 Polling question: esmd is managed by which agency. 1. NIH 2. CMS 3. CDC 4. HHS

14 Why esmd Matters esmd provides hospitals the ability to electronically exchange medical documentation data with CMS to: Eliminate the requirement of sending paper medical documentation to support claims data sent to CMS for Medicare services rendered Create a secure electronic mechanism allowing for the HIPAA compliant exchange of medical documentation between a hospital and CMS Enable the electronic tracking of all information exchanged through the esmd portal with CMS to support audit requests Allow providers the ability to respond quickly and securely to time-sensitive RAC and other Medicare audits through participation in the esmd program

15 Combating Waste with esmd Improved productivity: electronic document collection, storage and exchange improves staff productivity by reducing the time spent filling out forms, copying, mailing or faxing audit responses Reduced costs: esmd eliminates costs associated with manual, paperbased processes Decreased denials: electronic medical documentation speeds up response processes eliminating untimely record submission denials and rework requests Enhanced tracking: esmd provides an electronic audit trail proving documents were both sent and received

16 esmd as HIE esmd is an Health Information Exchange (HIE) for claims support documentation Through esmd, hospitals can provide supporting claims documentation in response to an audited claim Hospitals are ensured their records are received within the allowable response period; patient s data is secure; claims are paid more quickly than if paper-based

17 esmd is Not Mandatory

18 How esmd Works

19 esmd Gateway What is the esmd Gateway: CMS worked with other federal agencies to fund the building of an open-source Nationwide Health Information Network Exchange (NHIN/NwHIN) Gateway now known as CONNECT to accept esmd transactions from providers The gateway went live on September 15, 2011; it s tested technology To gain access providers can purchase or build their own gateway or contract with a Health Information Handler (HIH)

20 Polling question: What is a Health Information Handler? 1. Access provider of esmd 2. Document collection of CMS 3. Software exchanging claims 4. Collection for esmd info

21 Using an HIH s Gateway A Health Information Handler (HIH) is any company that handles health information on behalf of a provider. Examples include: Regional Health Information Organization (RHIO) Release of Information (ROI) Vendor Electronic Health Record (EHR) Vendor Claim Clearinghouse Health Internet Service Provider (HISP)

22 esmd HIHs Participate voluntarily Receive no funding from CMS or ONC (Note: they may bill providers) Attend calls with CMS (scheduled) Build an ehealth Exchange Compliant Gateway Obtain a certificate, IP address, and share key with CMS Gateway Contractor Successfully onboard with the CMS esmd team and test with CMS Gateway Contractor Recruit providers to join

23 esmd Story: Boca Raton Regional Hospital Founded in 1967 Not-for-profit Boca Raton Regional Hospital health system with 400 licensed beds, more than 700 physicians, a nursing and support staff of more than 2,000 professionals and 700 volunteers Serves very large senior (Medicare) population -- more than 65 percent of its patient population -- A significantly higher Medicare population than the national average of 37 percent A consequence of such averages huge volume of requests frim Medicare for medical documentation to support claim submissions prior to and after payment receipt

24 Buried in Audit Paperwork A significant amount of patients on Medicare because of large retirement population in Florida leading to huge volume of RAC payment audit requests Medicare audits compromised the financial stability of the organization and continue to loom large over the entire industry Boca Raton Regional Hospital returned more money back to the Medicare program than any other hospital in the country as a result of the 3-year RAC Demonstration project -- $11 million between 2005 and 2008 During the period from 2011 through 2014, BRRH returned an average of $350,000 per year to the Medicare program as a result of medical documentation audit requests

25 A Numbers Game Estimated annual initial claims denials of $1,000,000 net revenue or >28% of total net patient revenue Greater than 90% of the appeals processes involved in addressing a denial are manual, paper-based Fax and mail require human and time intervention: esmd helps alleviate workloads in these scenarios

26 Paper Tigers Not unlike hospitals throughout the country, Boca Raton incurred significant recurring costs utilizing the traditional mailing options of paper and imaged medical records (CD/DVD), including: -- Paper costs -- Copy machine maintenance and leasing costs -- Costs of ink cartridge for copiers -- Toner costs -- Shredding costs -- Premium trackable shipping and postage costs -- Premium labor costs associated with processing auditor requests

27 Other Issues Encountered Costs associated with untimely submissions of records Slow response to time sensitive audits Daily monitoring of medical document receipt Limited time to gather paper from various subsidiary systems, like case management Compliance hindered by manual data gathering efforts

28 Cleaning Up Administrative Waste Health Affairs and the Robert Wood Johnson Foundation identified administrative complexity as a category of waste in U.S. healthcare spending Costs average between $107 and $389 billion annually* Claims: every step in the billing process has the potential for administrative waste: Excessive paperwork Back-and-forth interactions between provider and payer Nuanced contracts unique to each insurance company Different forms and ways each payer wants to exchange information Records sent but never acknowledged by payer *Health Affairs, Reducing Waste in Health Care, Dec. 12,2012

29 esmd Leads to Positive Results Boca Raton Regional Hospital is experiencing: Quicker payments: On average, 75 calendar days have been eliminated from the initiation of the CMS record request to the receipt of payment on claims where record review was required Reduced labor costs: esmd reduces the labor required to fulfill audit requests because there s no longer a need to print and mail paper documents or feed a fax machine or copying data to portable media (CDs, DVDs, etc) Fewer hard costs: no more paper, CD or shipping and handling expenses for the hospital related to Medicare and other payer audits Secure submissions: esmd transactions are secure and HIPAA-compliant, with all submissions tracked through a proven audit trail, ensuring no lost documentation and accurate calculation of timely filing requirements

30 The Biggest Benefits Since using esmd technology, and because the hospital is able to exchange health information, its financial outlook has improved because of more timely re-imbursements and lower costs The hospital has eliminated the administrative burdens of managing the flow of records to support the claims esmd has saved the hospital more than $4 million since it began exchanging medical documentation through the portal in 2012

31 Polling question: esmd will not improve which of the following? 1. Security of data 2. Costs associated with paper 3. Audit response times 4. Private insurer communication

32 We Recommend (CMS) Utilize educational sessions by CMS to navigate esmd and reduce audit risk (CMS) Establish processes to ensure billing in accordance with Medicare policies, ensure esmd connection (Boca Raton) Hospitals should set policies to define for staff the specific rules to help them reduce audit risks (Boca Raton) Hospitals should put in place automated workflow in the business office and in Medicaid records/him to ensure compliant billing (Boca Raton) Providers should conduct internal assessments to identify if their billing practices are in compliance with Medicare, ascertain corrective actions to promote and learn from past experience by tracking denied claims and addressing root causes of patterns.

33 More Recommendations (Boca Raton) Track actual dollars lost because of failure to meet timely record submission deadlines and related denial reasons (CMS/Boca Raton) Utilize esmd for faster processing of their audits: to ensure efficiency when responding to time-sensitive audits, versus sending records through the mail to ease administrative burden audits can cause for hospital staff to increase quality assurance and compliance of business office and other revenuedriven departments to integrate information from different systems, such as lab and billing, helping the hospital ready itself for future revenue reporting activities related to quality, efficiency and claims-based programs esmd ensures that physical records never leave the hospital

34 esmd: Exchanges Up, Expenses Down esmd Allows for Efficient Exchange of Health Information -- Financial outlook has improved because of more timely reimbursements esmd Transactions are Secure, Traceable and HIPAA-compliant -- No more shipping and handling expenses

35 Questions THANK YOU! Joyce Davis Rudy Braccili Jr., MBA, AAHAM-CRCE