Products & Technology

The HME Paper Chase

How providers are turning to document management to rapidly respond to audits, while driving cost, inefficiency from their businesses.

• By David Kopf
• Sep 01, 2012

When the words “Medicare audit” are uttered, it’s hard not to imagine the classic ‘70s novel and film, “The Paper Chase.” However in this industry’s version, instead of a Harvard Law student trying to hunt down the documents necessary to satisfy his tyrannical Contract Law professor, it is providers engaged in the maddening chase for documentation on often long-dormant claims that are suddenly being recouped. Moreover, it’s not just claims that are at stake, but the sobering fate of being put on 100 percent pre-pay audits if the auditors deem such a punitive step necessary.

Finding a doctor’s order has never felt so weighty.

“The audit process is really driving a lot of adoption in our customers,” says Gregg Timmons CEO of HME software maker MedAct. “There are really two types. There are HMEs that see the value of document imaging solutions right up front, or, number two, they realize, ‘Oh my gosh, I just got an audit and I need to go back six months to find all the charts and all the documentation for these 25 patients, and there are 50 types of invoices and claims, and good luck trying to find all that information.’ It’s a massively disruptive process.”

And luck is needed when all that information is in paper. Timmons says that is exactly why some providers practically — or completely — shut down for a week or two just to find all the components of paper files that auditors have requested. And that can be a big problem. According to the Association for Information and Image Management, 7.5 percent of all documents within a business are lost.

“If you think about it, if you have 50 claims that are audited, and each of those claims has five documents in it, multiply that out, that’s 250 documents,” he says. “The problem is, you don’t know which 7.5 percent of those documents aren’t going to be found. So, this is a big, big risk.”

The High Price of Dead Trees

But audits aren’t the only concern when it comes to paper filing. Providers are sitting on top of a giant cost center that revolves around document management. Maintaining paper filing systems, retrieving documents, moving those pieces of paper through the workflow, and ensuring those papers get returned to their proper files turns into an incredibly expensive process given all the time spent by employees engaged in those activities. Document management offers a better, easier and, above all, cheaper way to accomplish the same tasks.

“If you think of the life cycle of a piece of paper as it passes through the organization, and how many people have touched it, copied it, and dealt with it, that comes to about $20 dollars in total labor,” Timmons explains. “That’s really high in a market where we have such pressures on margins.”

The costs get even worse when documents are misfiled, which cost on average six times a documents typical manpower footprint, $120, to locate and retrieve. (The local copy shop should be so lucky to charge that much a page.)

“So you start putting these numbers down and it’s an enormous amount of productivity wasted keeping documents in paper form,” Timmons says. “If you have a document in electronic form in a document management system, it’s a matter of right-click and ‘print document.’ You can package them up as a PDF, zip them up, send them electronically, or you can print out the paper and deliver it. A much, much better efficiency in responding to the audit requirement.”

And when providers compare the cost of lost productivity due to managing paper files versus the purchase price of a document management system, Timmons says the argument becomes pretty overwhelming.

“It’s at a price point that is shockingly low in comparison of the value they deliver,” he says. “Typically, these systems pay themselves back in less than four months.”

Accreditation, Backups

Moreover, document management is a valuable tool in ensuring that providers stick to the documentation requirements related to their CMS accreditation for billing Medicare, as well as private payor accreditation.

“I think this industry will finally begin to realize that the source documents — CMN, doctor’s orders, and so on — are pieces of the medical record; they are pieces of the EHR,” Timmons says. “If you look at accreditation standards on information management, they want you to make backups of the information. How do you do that? You make another piece of paper and keep it off-site. How many providers are doing that?”

But if those documents are integrated into the providers’ information system, backing up that data and protecting it is an automated process.

Approaching Document Management

Timmons estimates that roughly 70 percent of providers have not implemented any kind of document management system, but, that said, of those buying his systems today, the top module that they add onto their MedAct system is its document management module. Clearly, audits are pushing providers to give document management a closer look, but where do they start?

Perhaps the best place for providers to start is by thinking about how their document management system should function, Timmons says. Do they simply want an electronic filing cabinet for their documents, or do they want a fully fledged document management system that turns their organization into a paperless provider business? Obviously, the latter promises more value than theformer, but the comfort level of a provider and its staff for fully transitioning to a paperless system can understandably be a little tenuous.

That said, the demand for a fully fledged document management is what software maker Brightree has been seeing from its providers, Chris Watson, Chief Marketing Officer of Brightree. Brightree recently began offering its own document management system, after having incorporated support for its users that were also using RemitData’s document management. When it comes to audits, Brightree’s document management system reinforces providers’ documentation processes by using optical character recognition technology to double-check valid dates, ensure physician signatures are present and similar elements that are critical in ensuring that documentation is correct and will pass audit muster.

But that’s only telling part of the story. Brightree aims to make HME providers’ businesses “document-aware organizations.” In this landscape, document management is infused into the provider’s workflow, and this corresponds with provider’s needs.

“I think the number one driver we’ve heard for document management is the increased efficiency,” Watson says. “The second would be response to audits, and I think those things go hand-in-hand. Because providers are having to have more of their staff members focused on chasing documentation and responding to these audits, they are looking for anything that creates efficiencies in that process. So things like automatically assigning documents to the proper patient so they aren’t sitting electronically in a bin somewhere will dramatically reduce the time and energy that humans have to spend going to search for the documents.”

Implementing a holistic approach to document management such as what Watson describes isn’t all that tough. From a technology standpoint, most document management systems for HME providers are integrated in their HME management systems. Moreover, from a staff perspective, team members are almost chomping at the bid to get them. Staff are as tired of wasted time and effort as management is.

“I can tell you in the first month of deploying this solution we’ve had more than 100 customers sign up for it,” she says, adding that she advises providers to seek a system that is fully integrated with their HME software. “There were two key provider challenges that drove our development of this system. Number one is having their patient information in two disparate systems and having to keep both up to speed. And second was teaching their staff yet another software program. By having it as a drop-down in the menu system that they work with every day, it makes it very easy to adopt.”

esMD: The Electronic Hand-Off

Of course, one providers have their document management system in place, and all documentation is electronic, they still need to be able to get documents to auditors when they receive an audit request. The traditional method has been to print those documents out and send them via fax or FedEx to the audit contractor, but now providers have an electronic option that is furthering the usefulness and cost-savings of their document management systems. Using Medicare’s Electronic Submission of Medical Documentation (esMD) system, providers can send the documents electronically to audit contractors, obviating even more the need to waste time and energy that would be spent on “analog” paper processes.

“The way we’ve done it within our software, documents are already scanned into the system, and when a request for an audit arrives all the provider does is select the documents in question and it is sent electronically directly to the review contractor,” says Richard Mehan, president of HME software maker Noble House.

In terms of file format, Mehan says that while Noble Direct’s document management system supports a wide range of file formats (TIFF, PDF, bitmap, JPEG, etc.) , the accepted media for esMD seems to be PDF. In terms of file size, esMD accepts a maximum of 19 MB, and if a file is larger than that, it gets broken into smaller segments that are then sent to the auditor contractor.

Overall the system works, but CMS is still putting it through a phased implementation, according to Mehan. Since esMD is a new process for CMS, it has had its bumps like Medicare’s other electronic efforts, Mehan says, but those bumps are getting smoothed out.

“The review contractors are getting up to speed on receiving the documents electronically, so there are a few kinks that have had to be worked out, but it seems to be working rather smoothly now,” Mehan explains. “It’s a step in the right direction.”

That phased implementation of esMD will be further reaching, as well, he adds. Right now, in phase one of its implementation, esMD is being used for auditors’ documentation requests, but further down the line, its usage will be broadened to include receiving support documentation for Medicare claims, as well. (To learn more about esMD, visit www.cms.gov/ESMD.)

What’s Next?

The world of electronically managing documents in the same way a business manages any other kind of data has changed considerably over the years. MedAct’s Timmons started his career in document imaging roughly 20 years ago with Eastman Kodak and notes that the world of document imaging and document management has evolved since then into the realm of what is called enterprise content management (ECM).

In its basic sense, document imaging means creating a digital image of a document; basically scanning it in. Document management refers to creating a system that lets businesses store, retrieve and add context to those document images. In the case of providers, this would mean scanning in all the documents related to a specific claim; being able to relate those documents against a patient or a referral partner, for instance; and being able to quickly retrieve and share those documents. Obviously, this vastly cuts down on costly time and effort spent properly storing documents as well as chasing them down.

But the world of document management hasn’t stopped changing. Now, it’s not just documents that are being managed in these systems, but all sorts of content, Timmons explains. Hence, ECM.

“If you look at what providers will be doing, they will be moving more into the electronic world, such as e-commerce for orders that commonly don’t use CMS, and things like that,” he explains. “If information is coming off of the web site, why wouldn’t that be used as documentation? Voice mails, e-mails, that’s what the concept of ECM is.”

So, ECM could be the next step for providers.

“Typically, the adoption curve has always been, first, get the documents out of paper and into electronic,” Timmons says. “It’s the most efficiency you can drive; it’s the biggest ROI you can hit. Once you do that, and people realize, ‘Hey this doesn’t hurt, and it actually feels pretty good,’ then you start realizing that you want the other pieces of content that make up the tapestry and fabric of a patient engagement in the system, as well.”

This article originally appeared in the September 2012 issue of HME Business.