​A central goal of the Patient Protection and Affordable Care Act is to provide health insurance for more Americans, and a cornerstone of this legislation is the widespread implementation of health information technology (HIT) and electronic health records (EHRs) among key stakeholders.

 

Long term care providers are evaluating their technology infrastructures as the Centers for Medicare and Medicaid Services’ (CMS') new model of rewards and penalties for interoperable EHRs takes shape. The April 18, 2011, announcement of the availability of registration for the Medicare and Medicaid EHR incentive programs is also stimulating new HIT investment among eligible providers.

 

According to a recent survey from IVANS, there has been a significant increase in the use of EHRs over the past two years. The survey participants represented a wide range of businesses in the health care industry, including: hospitals, private medical practices, clinics, home care, skilled nursing, durable medical equipment, hospices, rural health clinics, laboratories, and billing companies.

 

Twenty-eight percent of health care professionals who responded to the study said they are already using EHRs or electronic medical records (EMRs), and almost 40 percent have implementation plans within the next 12 months to two years. This represents a 60 percent increase over those providers who participated in IVANS 2009 survey.

Hospitals are the largest segment of providers using EHRs or EMRs, at 47 percent, according to the survey. In comparison, home health care and skilled nursing facilities represented the smallest numbers, with 26 percent and 21 percent, respectively.

 

Home health care and skilled nursing are currently not eligible for the EHR incentive program. These factors, along with lack of HIT expertise, budgets, and resources explain why 34 percent of home health care, and 40 percent of skilled nursing facilities, have no immediate plans to implement EHRs or EMRs.

 

While EHR incentives are not yet available for everyone, the government’s push to advance technology through such legislative acts as the Affordable Care Act and Health Information Technology for Economic and Clinical Health (HITECH) Act has led many providers to research where they can receive immediate benefits by improving their day-to-day administrative processes.

 

They are implementing real-world solutions that automate specific workflows and yield savings today, while maintaining a longer-term view on HIT programs that have little to no impact on their businesses right now.

 

For example, by integrating digital and web-based technologies into compliance and audit workflows, providers can comply with mandates faster, and save time and money by reducing manual paperwork.     

In accordance with the health care reform bill, Medicare beneficiaries requiring home health care services are required to have a documented face-to-face encounter with a physician or nurse practitioner within 90 days prior to the start of home health care or within the first 30 days after the start of service.

 

This new mandate is in addition to the current requirements of a CMS Form 485 (also known as the Home Health Certification Plan of Care), which home health care agencies use to certify a patient’s services. For hospices, a face-to-face encounter is required between a physician or nurse practitioner and a Medicare recipient enrolled in hospice care before the 180th day of recertification and for each 60th day of recertification period after that date.

 

CMS enacted this mandate so physicians would have more accountability and have the most up-to-date information when substantiating a patient’s eligibility. However, many providers find these face-to-face requirements to be an arduous task that can delay patient care and impact cash flow.

 

In fact, a home health care agency in Baltimore, Md., said that since January, the face-to-face mandates have already affected their cash flow by more than $160,000, because the paperwork often needs to be sent multiple times, sometimes taking days or weeks for approvals.

 

Most home health care and hospices currently mail or fax in forms to physicians for their completion and signature, but there is existing and affordable technology that can speed up this process. Using a web-based health information exchange (HIE) platform, in conjunction with an electronic  or digital signature applications, makes the process of sending and receiving patient care documentation occur within seconds instead of days, and it is relatively simple to implement

 

First, the home health or hospice creates a CMS Form 485 and/or a face-to-face document either manually (by scanning in the form) or electronically (via an EMR or form builder). The provider then attaches the document, indicating where a signature is required and securely sends the file to the physician via email.

 

 

 

Upon receiving the document, the physician electronically inserts his signature and then emails the file back to the home care agency or hospice. Alternatively, the physician can print out the CMS Form 485 and/or face-to-face document, sign his name manually and fax it back to the provider.

 

In both instances, the patient care documentation is captured and tracked automatically via the HIE platform.

 

Not only do web-based HIE platforms and electronic signatures enable providers to comply more quickly, these types of technologies can be used for the transfer of other legal documentation, such as doctor’s orders and death certificates.  

Another important goal of health reform is to reduce skyrocketing health care expenses by focusing on anti-fraud and recovery audits. For example, the Recovery Audit Contractor (RAC) program was developed by CMS to identify and correct overpayments and underpayments from non-compliant medical claims submitted by providers.

 

CMS has collected more than $313 million in Medicare overpayments through the RAC program since October 2009 and has paid providers $52.6 million in underpayments.

 

IVANS’ 2011 Hospital RAC Audit Survey, of which 125 hospitals responded nationwide, found that 73 percent “agreed” or “somewhat agreed” that these audits are helping to reduce errors and fraud. But, overall, 60 percent of the respondents felt the RAC process was not fair.

 

Interestingly, 64 percent of those surveyed who have been through a RAC audit, thought the appeals process was fair. According to CMS, Medicare providers won 64 percent of the claims they appealed during a three-year RAC Demonstration.

 

While this was a major win for providers, it still creates a significant drain on the administrative and financial resources of a health care organization.

 

To facilitate the RAC program for providers, CMS initiated the electronic submission of Medical Documentation (esMD) pilot, of which eight health information handlers (HIH) are currently participating. When a Medicare provider is notified of an audit by a RAC or Medicare Administrative Contractor (MAC), the provider has 45 days to submit medical records to substantiate the Medicare claim.

 

There are currently three options to choose from when responding to medical documentation requests: mailing in paper documents; mailing in a CD containing PDF or TIF files; or transmitting files via fax. Under the esMD pilot, providers can securely exchange and track the audit process of medical documentation by leveraging a

web-based HIE portal, Nationwide Health Information Network (NHIN) standards, and CONNECT, an open- source software solution that supports HIE. CONNECT uses NHIN standards and governance to ensure that HIEs are compatible with other exchanges being set up throughout the country.

 

With providers having only 45 days (from the time the RAC letter is received) to send over medical records to review contractors, together, these technologies make the esMD program faster, less expensive, and more reliable than shipping these documents manually. 

 

Providers can also archive their files to ensure documentation is readily available if there is an appeals process.

 

During Phase 1 of the esMD pilot, which launches this week, Medicare auditors, including RACs, MACs, and others, will continue to send medical documentation requests via paper mail, and providers will have the option to respond electronically. 

 

During Phase 2 of the pilot, which is expected to launch in 2012, RACs will electronically send documentation requests to providers when their claims are selected for review.

According to the American Medical Association’s (AMA) 4th Annual Health Insurer Report Card, the rate of inaccurate claims increased by two percentage points since last year, and lack of patient eligibility for medical services continues to be the most frequent reason for denials.

 

An IVANS Provider Survey of 500 health care providers revealed that 59 percent of respondents lost revenue due to Medicare benefit ineligibility. Providers can, however, minimize this risk by taking advantage of online eligibility verification through Medicare’s HIPAA Eligibility Transaction System (HETS). The benefits are significant. By providing up-to-date information on a patient’s eligibility for Medicare benefits before services are delivered, providers can dramatically reduce claims denials and lower their risk for uncompensated care. Providers are also saving a lot of time by accessing eligibility information electronically (which typically takes less than 5 seconds per inquiry) versus the minutes and hours it takes to get similar data over an interactive voice response (IVR) system.

 

Hospice of the Valleys (HOV), a non-profit hospice headquartered in Murrieta, Calif., replaced its IVR system with electronic Medicare eligibility verification and upgraded it claims workflow to broadband technology. In fact, HOV uses a web-based HIE platform for accelerated access to the entire claims workflow.

 

This includes batch and interactive claims submission; retrieval of front-end reports; claim status requests/responses via direct data entry (DDE); claim correction; and electronic remittance advice (ERA).

Future claims processing growth and updates are made seamlessly via an HIE platform, so HOV does not have to download new software as Medicare changes and healthcare mandates take effect. And, HOV is planning to leverage this technology to assist with face-to-face encounter requirements.

 

With so many changes going on as a result of the Affordable Care Act and HITECH Act, providers that take a fresh look at simplifying their administrative workflows will be better prepared—from a financial and technology perspective—when longer term HIT initiatives come to fruition. Most importantly, they will be readily equipped to meet the increasing demands of delivering quality care to their patients now and in the future.