Each year, the Medicare Fee-For-Service (FFS) Program makes billions of dollars in estimated improper payments. The Centers for Medicare & Medicaid Services (CMS) employs several types of Review Contractors to measure, prevent, identify, and correct these improper payments. For more information about Medicare improper payments, visit the "Payment Accuracy" website by clicking the link titled "Improper Payments" in the 'Related Links' section below.
Review Contractors find the improper payments by selecting a small sample of claims, requesting medical documentation from the provider who submitted the claims and manually reviewing the claims against the medical documentation to verify the providers' compliance with Medicare's rules.
Review Contractors request medical documentation by sending a paper letter to the provider. In the past, these providers had only two options for submitting the requested records – sending a letter or fax.
The CMS eHealth initiative aligns health information technology (Health IT) and electronic standards programs. The eHealth programs will help improve the health care system including reducing provider paperwork through administrative simplification. For more information about the eHealth initiative, click the link titled "CMS eHealth" in the 'Related Links' section below.
Electronic Submission of Medical Documentation System (esMD)
During Phase 1 of esMD, providers still receive medical documentation requests via paper mail but have the option to electronically send medical documentation to the requesting Review Contractor. Phase 1 of esMD went live on September 15, 2011.
During Phase 2 of esMD, providers will receive electronic documentation requests when their claims are selected for review. The CMS plans to go live with esMD Phase 2 in the future.
To view a graphical depiction of esMD, click the link titled "Introducing esMD to Providers, RCs, and HIHs" in the 'Downloads' section below.
Prior Authorization Demonstrations
In addition to Power Mobility Devices (PMD) Prior Authorization requests, the esMD system recently began accepting Repetitive Scheduled Non-Emergent Ambulance Transport and Non-Emergent Hyperbaric Oxygen Prior Authorization requests.
For more information about the PMD, Ambulance, and Hyperbaric Oxygen Prior Authorization processes, visit the esMD "What’s New" page and click the following links in the 'Related Links' section below.
- “Prior Authorization of Non-Emergent Hyperbaric Oxygen”
- “Prior Authorization of Repetitive Scheduled Non-Emergent Ambulance Transport”
- “PMD Prior Authorization”
To view a list of which Health Information Handlers (HIH) offer this service, click the link titled "HIHs that offer Prior Auth submission services" in the 'Related Links' section below.
Electronic Submission of Medical Documentation (esMD) Annual and Semi-Annual Program Reports
The Centers for Medicare & Medicaid Services (CMS) released the "2014 esMD Annual Program Report (10/012013 - 09/30/2014)" and the "esMD Semi-Annual Program Report (10/01/2013 - 03/31/2014)". To view the esMD annual and semi-annual reports, click the links in the 'Downloads' section below.
- Prior Authorization of Non-emergent Hyperbaric Oxygen
- Prior Authorization of Repetitive Scheduled Non-Emergent Ambulance Transport
- PMD Prior Authorization - Opens in a new window
- Medicare Fee-for-Service Compliance Programs
- HIHs that offer Prior Auth submission services - Opens in a new window
- Improper Payments - Opens in a new window
- CMS eHealth - Opens in a new window
- Page last Modified: 03/12/2015 9:32 AM
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