In a provision glossed over by most, the 2021 Inpatient Prospective Payment System (IPPS) Final Rule introduced a requirement that all providers transmit all records to Quality Improvement Organizations (QIOs) via electronic means as of Oct. 1, 2020. As a reminder, the QIOs perform several types of reviews for the Centers for Medicare & Medicaid Services (CMS). On a post-discharge basis, the QIOs review high-weighted DRG claims, short stay inpatient admissions, complaints about violations of Emergency Medical Treatment and Labor Act (EMTALA) regulations, readmissions, and complaints about quality of care. On a concurrent basis, they review discharge appeals and non-coverage appeals. Now that Oct. 1 has come and gone, the questions begin, mainly in regard to the concurrent reviews wherein time is of the essence and the normal 14 days allotted to send records is clearly not appropriate.
Although electronic transmission is required, is not an absolute requirement. First, hospitals without “an electronic medical record system that is capable of transmitting documents electronically” can request a waiver from the QIO to continue faxing documents. But there is no clear definition of “capable” provided for this waiver. To illustrate the ambiguity, if the electronic medical record (EMR) is capable of transmitting documents, but to do so requires a complex reprogramming of the system or the purchase of a costly add-on, does that qualify for a waiver? One provider inquired with their QIO and was told that a waiver must be requested every time the hospital wants to send a medical record via fax. It was later clarified that a waiver was good for a year, and not required with every submission. The waiver also states that “the waiver request will be either accepted or rejected within a few minutes,” which calls into question how these requests will be reviewed so quickly. Will the QIOs have a person dedicated to monitoring the waiver submission portal at all times? Will waivers be reviewed on evenings and weekends?
If a waiver is issued, the provider will be paid $0.15 per page to fax the records. If a provider transmits the documents electronically, they will be paid $3 per chart. But in a strange twist, although electronic transmission is required, if a provider chooses to not transmit documents electronically and a waiver is not requested or approved, the provider can continue to fax the records, but they will not be paid any fee from the QIO.
For the regulation wonks like myself, this is reminiscent of the condition of payment that CMS imposed when it established the prior authorization process for cosmetic-like procedures on July 1. That regulation established that obtaining prior authorization was required, and claims without the authorization number would be denied. But that denial comes with full appeal rights, so the provider could then submit the medical records – and, if medical necessity for the procedure was present, the claim would be paid in full.
As hospitals scramble to implement this new regulation, several options for electronic transmission exist. The already established esMD system can be used and is accepted by both QIOs. Hospitals may also have the ability to transmit records directly from their EMR via direct secure messaging. In many cases, this requires contracting with a health information service provider that builds the gateway between the EMR and the QIO via the DirectTrust network, which is HIPAA-compliant. And finally, both QIOs have set up portals that can be accessed on their websites to directly upload the requested records.
The first issue that must be addressed is the often hybrid nature of the medical record during a hospital stay. While much of the record is electronic, many documents are paper, including the Important Message from Medicare (IMM), the Detailed Notice of Discharge, and hospital-issued non-coverage notices. Each hospital must determine a process to upload these documents into the EMR prior to preparing the record for transmission. The usual process in most hospitals is that the paper elements of the record go to the health information management (HIM) department after discharge, where they are tagged and then scanned into the proper section of the EMR by trained staff. With a discharge appeal, which often occurs outside of usual business hours, there must be a process established to get those documents rapidly scanned into the EMR. HIM personnel are rightfully very protective of the fidelity of the medical record, and their input should be sought when developing this process.
Then, providers must determine how the medical record, once complied, will be transmitted. In some EMRs, the system, often through a release-of-information module, is able to create a single PDF file with all the required elements, and load that file into an efax module to be faxed. The PDF file remains within the EMR. But the portals developed by the QIOs require the provider to upload the document. That means the provider must create the PDF file (perhaps through the same release-of-information module), and then save that document to a file location that can then be accessed when the provider clicks the “choose file” option on the QIO portal. Providers must ensure that the saved location is appropriate for this purpose, with the appropriate security and access limitations and tracking.
The final question is whether it is worth the time and effort. Establishing this new procedure will require significant time and resources for all providers, involving case management, HIM, IT, compliance, and others. It may make what is now a well-established, efficient process into a multi-step process, adding time and frustration. CMS has talked extensively about administrative simplification and allowing providers to concentrate on patient care. This seems to reflect the opposite. And the $3-per-chart payment will come nowhere close to covering the costs. If the QIOs continue to accept faxes, which get converted to electronic images on the receiving end just as if they were transmitted electronically, perhaps the best option for now is to continue the current process, and hope that if enough providers continue to fax, the QIOs will continue to keep their fax lines open.
Healthcare is often laughed at by other industries for the continued reliance on faxing, but no other industry has such stringent security and documentation requirements. If the current system is not broken, why try to fix it?
Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI, FABQAURP is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic.