Frequently Asked Questions & Glossary of Terminology

 

Refyne Platform and Electronic Submission of Medical Documentation (esMD)

The information contained herein is meant to provide a high-level understanding of the Refyne platform, featuring Refyne Audits and to educate readers on the Centers for Medicare & Medicaid Services (CMS) Electronic Submission of Medical Documentation (esMD) program.

REFYNE PLATFORM OVERVIEW

The Refyne™ platform featuring Refyne Audits will enable providers to electronically respond to Medicare fee for service (FFS) audit requests for additional documentation. By implementing a streamlined, automated, electronic audit response process, providers can expect to experience fewer claim denials, more timely responses and improved tracking of audit documentation.

What is the Refyne platform?

Refyne is a cloud-based, SaaS platform that will serve individual healthcare providers, medical groups, hospitals, health systems, and other organizations. The platform features Refyne Audits with functionality that simplifies audit response workflows, enabling more timely filing of Medicare fee-for-service audit responses; Refyne Attachments for commercial claim attachment / ADR submissions; and Refyne Authorizations for Medicare prior authorization submission.

How does the Refyne Audits solution work?

The Refyne Audits™ feature enables providers to respond electronically to Additional Documentation Requests (ADR) for pre-and post-payment audits, Recovery Audit Contractor (RAC) audits, level 1 & 2 appeals, and discussion requests.

Who will benefit from using Refyne Audits?

Refyne Audits is a fit for any provider that is:

  • Looking to upgrade their current RAC audit response process
  • Currently mailing or faxing audit responses (i.e., not utilizing esMD to receive and respond to Medicare medical documentation requests)
  • Ready to make process changes to save time and money by eliminating manual audit responses
  • Experiencing issues with timely filing of audit responses leading to claim denials
  • Not securing the maximum allowable reimbursement for services provided
  • Seeking to improve payment response times for audited claims
  • Looking to consolidate software tools, eliminating the need for separate data/screen scraping utilities
  • Concerned about the integrity of audit response data and associated processes

What examples of hospital departments can leverage Refyne?

Departments that will benefit from Vyne Medical’s Refyne platform include:

  • Revenue Cycle/Patient Financial Services for pre-payment audits/ADRs/commercial claim attachments
  • Health Information Management (HIM) for post-payment RAC audits/ADRs/commercial claim attachments

Can providers who are already participating in the esMD program use or benefit from Refyne?

If an organization already uses esMD, but is interested in moving to the Refyne platform, they can absolutely do so. Providers using Refyne will be able to take advantage of functionality that may not exist with their current vendor, such as eMDR. Additionally, Refyne presents additional functionality for prior authorizations.

If I currently use Trace®, can I also use Refyne?

Yes, Trace clients interested in Refyne can use both services, but Refyne is sold separately and will require organizations to go through Vyne Medical’s registration process.

Why should providers leverage Refyne for audit responses?

Providers can utilize Refyne Audits and esMD to:

  • Automate paper-based processes for responding to Medicare audits
  • Improve efficiency when responding to time-sensitive audits, versus sending records through mail or by fax
  • Ease the administrative burden that audits can cause for hospital staff
  • Increase quality assurance and controls of the business office and other revenue-driven departments
  • Enhance data privacy by ensuring that physical records remain in the hospital

What are the benefits and advantages of using Refyne Audits for esMD?

The benefits and advantages of using Refyne include:

  • Faster payment turnaround time – Improve payment turnaround to approximately six days versus three weeks using manual, paper processes

  • Improve productivity – Automation reduces administrative burdens on staff related to the time spent filling out forms, copying, mailing, or faxing audit responses

  • Reduce hard costs – Eliminate costs (paper, printing, postage/packaging, faxes, etc.) associated with manual document response processes

  • More secure, efficient record delivery – Provide a more efficient, encrypted means of delivering medical records to the requesting contractor

  • Enhance tracking – Provide an electronic audit trail with date and time stamps showing record delivery and receipt

  • Decrease denials – Enable faster responses to time-sensitive RAC and other Medicare audits, helping to eliminate untimely record submissions and rework requests

How is Refyne Audits priced?

Functionality in Refyne Audits requires that providers register for eMDR, designating Vyne Medical as their Health Information Handler.  Please contact the Refyne platform sales team to discuss pricing for your organization. Connect with us online or by phone: 800.864.2378.

ESMD PROGRAM QUESTIONS

What is esMD?

esMD is the Electronic Submission of Medical Documentation initiative launched by the Centers for Medicare and Medicaid Services (CMS) in 2011. It is a secure electronic communication channel for the exchange of supporting documentation between healthcare providers and Review Contractors (RC).

Why did CMS introduce esMD?

Audits required additional documentation to be submitted by providers to audit contractors in a timely manner in order to be compliant with deadlines, a process often fraught with inefficiencies.

Workflow without esMD:

  • Medicare Fee-For-Service (FFS) Program makes billions of dollars in estimated improper payments
  • CMS employs several types of Review Contractors (RCs) to measure, prevent, identify, and correct these improper payments
  • RCs find improper payments by selecting a small sample of claims, requesting and reviewing medical documentation from the provider
  • RCs request medical documentation by sending a paper letter to the provider in the form of an Additional Documentation Request (ADR)
    Provider responds with the appropriate documentation – an ADR response via mail or fax

Workflow with esMD:

The need to mail or fax documents is eliminated allowing:

  • Providers and suppliers to electronically submit requested medical documentation

  • RCs to submit ADRs to providers electronically

  • RCs to electronically exchange solicited documents with other CMS adjudicators

Provider submissions must be sent through a CMS Health Information Handler (HIH). Vyne Medical is a CMS-Certified HIH.

What can be submitted using Refyne Audits for esMD?

Medicare Fee-for-Service (FFS) providers and suppliers can send the following via esMD:

  • Responses to ADRs
  • First and second level appeal requests
  • Recovery Audit Contractor (RAC) and Durable Medical Equipment (DME) discussion requests
  • Advanced Determination of Medicare Coverage (ADMC) requests
  • Unsolicited claim related documentation

Is Vyne Medical a Health information Handler (HIH) for esMD??

Yes. CMS launched the esMD initiative in 2011 and Vyne Medical (formally MEA) was certified as a HIH in 2012, making us one of the most tenured service providers in the industry.

How many providers use esMD?

As of the CMS esMD 2018 Annual Report (FY 2017):

  • 60,000+ Medicare providers have participated in the program
  • 2.5+ million Medical Records were transmitted through the esMD program from September 2011 through September 2017
  • 61,000+ Prior Authorization Requests and 108,000+ Prior Authorization Decision/Notifications have been submitted through the program

Will providers get more Recovery Auditor medical documentation requests if they respond quickly? For example, if a provider submits requested documentation in 20 days, will this cause the Recovery Auditor to “restart the clock” earlier for the next round of medical documentation requests?

No. CMS allows Recovery Auditors to issue documentation requests every 45 days. This equates to 8 times a year. When medical documentation is received by the Recovery Auditor, this does not change the 45-day period for when Recovery Auditor could issue the next documentation request. The purpose of the 45 days is so that providers do not have several open documentation requests at one time. (esMD does NOT track and/or monitor the turnaround time between the request and the response.) For more information, please visit the CMS website.

Are providers required to electronically submit medical documentation?

Participation in esMD is voluntary. Providers who are content with faxing or mailing documentation to their RCs may continue to do so. However, providers who believe it would be more efficient to respond to documentation requests electronically are encouraged to contact an HIH like Vyne Medical to sign-up for esMD services.

Which type of Electronic Health Record must I have to use esMD?

esMD allows for the submission of Portable Document Format (PDF) files. Therefore, any Electronic Health Record system that is capable of exporting health information as a PDF file can be submitted via the Refyne platform.

Where can I find out more about esMD?

Visit www.cms.gov to learn more about the esMD initiative and review all program details.

GLOSSARY OF TERMINOLOGY

The following is an overview of common esMD-related terminology and acronyms.

 

ADR – Additional Documentation Request
When a claim is selected for medical review, an ADR is generated requesting medical documentation to be submitted to ensure payment is appropriate. Documentation must be received by the requestor within 45 calendar days for review and payment determination.

 

CERT – Comprehensive Error Rate Testing
While RACs look for claim payment errors made by providers, the CERT looks for errors in payments made by carriers. Hospitals and other providers are affected because when the CERT looks into a claim, the provider must submit the medical records, and if the CERT uncovers an error, the CERT will take back money from the provider. The CERT is specifically looking for errors made by fiscal intermediaries, Medicare administrative contractors or other carriers when paying providers’ Medicare claims. The CERTs examine random claim samples—often only looking at a very small percentage of a carrier’s claims. CERT documentation requests identify that the requested documents are to be submitted within 45 calendar days of the request.

 

CHIP – Children’s Health Insurance Program
CHIP provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid.

 

CMS – Centers for Medicare & Medicaid Services
The Centers for Medicare & Medicaid Services (CMS), is a federal agency within the United States Department of Health and Human Services (HHS) that administers the Medicare program and works in partnership with state governments to administer Medicaid, the Children’s Health Insurance Program (CHIP), and health insurance portability standards.

 

DME – Durable Medical Equipment
Durable medical equipment (DME) includes items that are used during treatment and recovery of an injury, illness or due to age related problems. They are typically non-disposable. They are often used both at home and at any location outside of the medical facility. Equipment can be used by caregivers, family members or the patients themselves. This category includes Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS).

 

eMDR – Electronic Medical Documentation Request
The eMDR is an Electronic form of an ADR. This electronic request functionality enables a fully bi-directional request and response within the esMD system and was launched in March 2020.

 

esMD – Electronic Submission of Medical Documentation
esMD is voluntary program launched by the Centers for Medicare and Medicaid Services (CMS) in 2011 and is meant to reduce the burden on providers responding to audit requests while supporting CMS’ broader eHealth Initiative. The esMD system helps different entities eliminate the need to mail or fax paper documents.

 

FFS – Medicare Fee for Service
The FFS Recovery Audit Program’s mission is to identify and correct improper Medicare payments through the efficient detection and collection of overpayments made on claims of healthcare services provided to Medicare beneficiaries, and the identification of underpayments to providers so that the CMS can implement actions that will prevent future improper payments in all 50 states.

 

HCPCS – Healthcare Common Procedure Coding System
HCPCS codes are used for billing Medicare & Medicaid patients. HCPCS is a collection of codes that represent procedures, supplies, products, and services which may be provided to Medicare beneficiaries and to individuals enrolled in private health insurance programs.

 

HIH – Health Information Handler
HIHs can provide software and communication services to help providers and suppliers securely exchange documentation with Review Contractors using the esMD system.

 

MAC – Medicare Administrative Contractor
A MAC is a private healthcare insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries. The DME MACs process Medicare Durable Medical Equipment, Orthotics and Prosthetics (DMEPOS) claims for a defined geographic area or “jurisdiction,” servicing suppliers of DMEPOS.

 

NPPES – National Plan and Provider Enumeration System
The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) mandated the adoption of standard unique identifiers for health care providers and health plans. The purpose of these provisions is to improve the efficiency and effectiveness of the electronic transmission of health information. The Centers for Medicare & Medicaid Services (CMS) has developed the National Plan and Provider Enumeration System (NPPES) to assign these unique identifiers.

 

PERM – Payment Error Rate Measurement
The PERM program measures improper payments in Medicaid and CHIP and produces error rates for each program. The error rates are based on reviews of the fee-for-service (FFS), managed care and eligibility components of Medicaid and CHIP in the fiscal year (FY) under review.

 

QIC – Qualified Independent Contractor
A QIC is an independent contractor that conducts Level 2 appeals for CMS audit reconsideration. A QIC is an entity that didn’t take part in the initial Level 1 decision. The QIC reviews requests for reconsiderations and makes independent decisions on cases referred for Level 2 appeals.

 

QIO – Qualified Improvement Organization
The QIO Program is based upon two core contract functions; quality improvement and case review. These functions include: reducing disparities in access and quality for priority populations, increasing use of health information technology, reducing adverse events related to healthcare-acquired infections, increasing care efficiency by promoting value within the health system, and improving the quality of life for patients nearing the end of life by alleviating pain with palliative care measures.

 

RAC / RC – Recovery Audit Contractor / Recovery Contractor
RACs review FFS claims on a post-payment basis. The RACs detect and correct past improper payments so that CMS and Carriers, FIs and MACs can implement actions that will prevent future improper payments.

 

ROI Vendor – Release of Information Vendor
A company that manages the release of information (medical records) for providers. ROI vendor services may include logging and tracking the request, retrieving the patient record from multiple locations in multiple formats, identifying the information needed to fulfill the request, requesting additional authorization, and, if needed, packaging and mailing of the response.

 

SMRCs – Supplemental Medical Review Contractors
The SMRC conducts nationwide medical reviews of Medicaid, Medicare Part A/B and DMEPOS claims to determine whether claims follow coverage, coding, payment, and billing requirements. The focus of the medical reviews may include vulnerabilities identified by CMS data analysis, the Comprehensive Error Rate Testing (CERT) program, professional organizations, and Federal oversight agencies. At the request of CMS, the SMRC may also carry out other special projects to protect the Medicare Trust Fund.

 

UPIC – Unified Program Integrity Contractors
UPICs are private sector organizations that review Medicare claims in order to assist the government in recovering overpayments to healthcare providers. UPIC audits are often generated through data analysis or by review of consumer complaints and most often target specific healthcare providers. UPICs primary goal is to investigate instances of suspected fraud, waste and abuse in Medicare or Medicaid claims. They develop investigations early, and in a timely manner, take immediate action to ensure Medicare Trust Fund monies are not inappropriately paid. They also identify any improper payments that are to be recouped by the MAC.

 

ZPIC – Zone Program Integrity Contractors
ZPIC audits are intended to check for and reduce the occurrence of Medicare fraud. UPICs (Unified Program Integrity Contractors) took over many of the responsibilities of Zone Program Integrity Contractors (ZPICs). Today, a few legacy ZPICs are still working on CMS projects but for the most part, all of their program integrity duties have been transferred over to UPICs around the country.

 

 

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