If it sounds too good to be true, it probably is.” This common adage makes a strong case for skepticism, and is particularly telling when used to reference home medical equipment providers' wait-and-see approach to new technology. Let's face it, HME providers can be an apprehensive bunch about embracing new technology. So, when it comes to electronically transmitting certificates of medical necessity, it should be no surprise that HME providers are reluctant to jump on the e-CMN bandwagon.

“When you are dealing with technology and a change in the way the system has typically run, there always is going to be a certain degree of apprehension,” says Jeffrey Frankel, president and chief executive officer of Trac Medical Solutions, Schenectady, N.Y. However, Frankel urges providers to give this new type of technology a chance because, he says, the benefits are worth a second look.

The e-volution of the e-CMN

Last September, the Centers for Medicare and Medicaid Services revised its Medicare Program Integrity Manual to include the acceptance of faxed and electronic CMNs. The PIM included instructions for how e-CMNs should be created and used, specifying that they must “adhere to all privacy, security, and electronic signature rules and regulations promulgated by CMS and DHHS. Additionally, e-CMNs must contain identical questions/wording to the CMS forms, in the same sequence, with the same pagination, and identical instructions/definitions as printed on the back of the hardcopy form.”

In what should have been a major shift in how the industry conducts business, the announcement was followed with very little action. Providers have begun taking advantage of the faxing option, though, says Elaine Hensley, professional relations manager for Palmetto GBA, the Region C DMERC.

If you examine the prototypes currently being offered, the same excitement should be there for e-CMNs, but it's not.

“I think the apprehension here is that Medicare came out with its program memorandum last September instructing the DMERCs to accept electronic CMNs without providing the DMERCs with any direction as to how to provide guidance for the electronic CMN,” Frankel says.

Why e-CMNs?

E-CMNs promise to offer the HME industry decreased overhead costs, increased compliance with Medicare requirements and increased revenue through reduced day's sales outstanding — three basic, yet vital, aspirations for HME providers.

Industry DSO averages range from 40 to 80 days, according to industry experts. Companies that advocate e-CMNs say they can reduce that time to less than a week, a financial incentive this industry should embrace, Frankel says. “One of the benefits is that e-CMNs will reduce the amount of time to days rather than months to process CMNs, which has a tremendous impact on a supplier's cash flow.”

And that benefit is what has software vendors, providers and industry leaders excited about this new opportunity. Few industries face the extenuated payment turnaround time most providers have come to expect. Yet, before providers can even hope to get paid, they must have the required documentation in place.

Bob Rice, chief executive officer of Austin, Texas-based eClickMD, a Web-based applications company, says it often takes 45 to 60 days for physicians to turn around paperwork, mainly because it is not a priority for them. Having an electronic means of communicating with physicians and their staffs can bridge that gap and reduce the turnaround time to less than a week. “Physicians are more receptive to the electronic process because it is an organized system and they have the ability to see all the documentation in one place,” he says.

Physically handling CMNs also is costly in terms of employees' time and effort. An electronic system can eliminate both the time employees invest in the process and the potential for human error that increases with each person who handles the form.

Tom Connaughton, president of the Alexandria, Va.-based American Association for Homecare, agrees. “[E-CMNs] can ease the administrative burdens of actually getting a CMN done correctly,” he says. “Currently, [processing] CMNs is a very time-consuming, labor-intensive task. By doing it electronically, it should be much easier for the doctors and a lot simpler for [providers].”

An additional benefit of the e-CMN system, says Kim Brummett, director of reimbursement for Advanced Home Care in Greensboro, N.C., is that it truly is a paperless system — meaning, among other things, there is a significantly lower chance of losing paperwork.

Increasing Compliance

For HME providers, remaining compliant with Medicare regulations is a full-time business in itself. On a daily basis, providers must pay attention to the latest rules and regulations and avoid any activity that appears abusive of the system. Fortunately, e-CMNs also can assist with compliance. “Being able to audit or to identify anything that you have stored electronically is so much easier than doing it on paper,” says Albert Prast, chief information officer and chief technology officer for Rotech, an Orlando, Fla.-based national HME provider.

Cara Bachenheimer, an attorney with the law firm of Epstein, Becker and Green in Washington, agrees with Prast and says she is optimistic about the impact e-CMNs can have on the industry's ability to remain compliant and prove compliance.

Brummett is examining the available systems and says that a major plus will be the ability to internally set “flags” that require physicians to answer each required question, which will reduce incomplete forms that must be sent back. “[The system] can't make [physicians] answer it right,” she says. “But, it can make them answer it.”

Neil Caesar, president of the Health Law Center in Greenville, S.C., and principal of Caesar Cohen Consulting, agrees. “I think it will be great if doctors cannot transmit the document if certain boxes are not complete,” he says. “You can't tell the doctor what to say but you can give instructions so it's easy for him to understand what he is supposed to do.”

It appears that e-CMNs can benefit honest providers by increasing their ability to work within the requirements of the Medicare program. But, can they decrease fraudulent activities? “I think if your goal is to cheat the system the possibilities are infinite,” Caesar cautions. “Cyberspace, in some ways, is more ripe for abuse because it's ill-understood by most people; therefore, there are ways to exploit it because people don't know what to look for.”

Getting Paid

In the early 1990s, Rice was managing home care companies and was astonished at how long it took companies to get paid. This inspired Rice to create the original eClickMD product. “The product was developed because I saw how much the accounts receivables were increasing on all these companies,” he says.

Today's timeframe for getting paid is not much better, but e-CMNs may be able to help providers change that. “The quicker you have the document in your file, the sooner you can draw up your claim to one of the four DMERCs for adjudication and reimbursement,” Frankel says. “Today, the industry [DSO] average is around 82 days from beginning to end — beginning being the actual creation of the CMN to receiving reimbursement from Medicare.”

Frankel says it is time for a change. “For years, the HME industry has been seeking a way to provide a more efficient way of managing the paper flow,” he says. “I think the time has come.”

Embracing New Technology

For providers, cost is a natural concern when it comes to evaluating new technology. The most important questions are: Can I afford to do this? And, can I afford not to do this?

To date, three organizations — AAHomecare, eClickMD and Trac Medical Solutions — are offering e-CMN transmission systems, each in various stages of development. The most important feature each emphasizes is that this technology is affordable. Although there will be a transaction fee — from $1 to $5 — it still costs less than the traditional means.

“We performed activity-based costing to the supplier on the CMN process and we were coming up with numbers like $28 per CMN,” Frankel says. “Even if the range is $25 to $30, when you look at the individuals and time involved, you can get a feel for why the cost is in that $28-dollar range.”

Software acquisition does not have to be costly, either. Prast, who has been working with AAHomecare to produce its e-CMN white paper, says users of the AAHomecare prototype could use the Internet to access the software. This format will be similar to that offered by eClickMD and Trac Medical.

Cost to physicians also will be nominal, which is an important consideration, because convincing them to transition to electronic processing is essential. “If physicians don't adopt this, you have nothing,” Rice says.

So, how do you convince a physician to come on board? First, Rice says, you detail the benefits to him, emphasizing that electronically completing CMNs can reduce his overhead expenses by freeing his staff to do things other than push paper.

“The key will be whether the physicians are willing to do this,” Connaughton says. “We hope and expect that over a period of time physicians will see the benefit of the e-CMN and embrace it.”

Brummett feels that physicians might be willing to work toward creating better efficiency in the system by communicating with providers electronically. This may be the best selling point.

Calculating Trust

One trepidation for providers is that the system they choose may not be secure or conform to the Health Insurance Portability and Accountability Act compliance standards. How can you know if the document has been altered or if the physician's signature is real?

For Brummett, these are paramount questions that must be answered in the beginning of the process. “You have to feel comfortable that you are in compliance and that you will be okay in the event of an audit,” she says.

Fortunately, the technology used is “smart” enough to cover all the security issues, Rice says. “The authentication of the users is tremendous. There is a lot of workflow that we have gone through in developing because we issue our own digital certificate, which is similar to the American Medical Association's VeriSign certificate,” he explains. “That is how we recognize both the receiver and the sender.”

He adds that there is heavy-duty security at the server level. “For everything that goes through the system, we know how it was sent, who the user was, what machine was used, where it went and who received it,” he says.

Current systems take security very seriously. Frankel says Trac Medical's solution requires physicians to digitally sign the e-CMN after logging on with a secret password. “The suppliers do not have the credentials nor do they have the physician's passwords to do those things,” he says. “With this type of system, you eliminate the ability of the supplier to make changes to a completed CMN and you eliminate the ability of the supplier to complete section B or forge a physician's signature.”

Caesar advises providers to ensure the system they choose is HIPAA-compliant. “The e-CMNs must adhere to all privacy, security and electronic signature rules and regulations promulgated by CMS or DHHS, which include HIPAA requirements,” he says. “Providers need to have a process by which they can reasonably conclude that the signature is the doctor's signature. A danger would be if someone at the other end signed on behalf of the doctor,” which, Ceasar says, is more difficult than it appears.

“There is no way to verify the physician's involvement except by making sure that at least you asked that question or are clear in your request for the CMN that it must be signed by the physician and that a signature by anybody other than the physician will not suffice,” Caesar says.

It also is important to consider state and federal privacy laws, which require that the information contained on the CMN is received only by the doctors who are involved. Caesar urges providers to remember that the transaction will be creating a permanent medical record. The transaction must follow current guidelines, which means a system of checks and balances must be in place to prevent errors.

The technical details are overwhelming and many providers may wonder if e-CMNs are just the latest techno-hype. However, experts urge taking a hard look at the automated process and its benefits and ease of use. Rice likens the process to e-mail, which isn't difficult — on the contrary, its organized structure simplifies many daily tasks. The same can be said for e-CMNs.

In an industry that often proves to be cautiously optimistic, HME providers who have spent time studying the process of electronically submitting CMNs are showing their support with strong optimism. “From a compliance perspective, it's a whole lot easier; from a [financial] standpoint, there are real dollars saved in terms of seeing cost eliminated; and [providers] are able to submit their claims more quickly, so you are saving in terms of the resources you put into getting paper documents completed,” Bachenheimer adds.

A New Meaning to Getting the Doctor on the Line

One of the obstacles to implementing e-CMNs is physician participation. Many question whether physicians are “computer-savvy” and have the systems to move forward into the electronic age. But, according to two recent surveys, these assumptions could not be further from the truth.

A 2001 American Medical Association survey found that in 2000, 75 percent of physicians were computer users and 70 percent accessed the Internet. Communication, medical information and news were the top reasons for Internet access. Internet use as a business practice ranked fifth.

And the Boston Consulting Group's recent survey, “Doctors Say E-Health Delivers,” offers statistics that are even more encouraging. Ninety percent of doctors research clinical information online, according to the report, and one-third have adopted Internet technologies to enhance the care they offer, saying these tools have enhanced their efficiency and quality of care. These technologies include: electronic medical records, electronic prescribing, online communication with patients and remote disease monitoring.

Currently, the BCG report notes the following:

• Twenty-six percent of physicians are communicating with patients over the Internet

• Twenty-two percent are relying on electronic medical records to store and track information

• Eleven percent are prescribing drugs electronically

“Everybody assumes that (physician acceptance will be a hurdle),” says Cara Bachenheimer, an attorney with the law firm of Epstein, Becker and Green in Washington. “There is always going to be a certain percentage of physicians who are never going to be electronically savvy, but I think we underestimate physicians' training in technology.”

Albert Prast, chief information officer and chief technology officer for Orlando, Fla.-based Rotech, agrees. “A year ago, I would have said the biggest problem was going to be getting the physicians to adopt (a new process),” he says. “Lately, we have had a lot of physicians saying, ‘We have PCs now, it would be really great if we could do this in an e-mail-like fashion.’”

EclickMD

SecureCMN
eclickmd.com

• Is a modular system
• Offers scanning option
• Has the potential for other medical forms
• Company offers products for variety of health care providers
• Currently available

e-CMN Prototypes: Your Options

If electronically processing certificates of medical necessity seems like a good idea, your first decision involves choosing a system that will meet your needs. Currently, there are three options to consider: The American Association for Homecare's Aahomecare.eCMN.org, eClickMD's SecureCMN and Trac Medical Solutions' CareCert. Each of these Web-based application systems is compliant with standards set forth by the Health Insurance Portability and Accountability Act of 1996.

American Association for Homecare

AAhomecare.eCMN.org
aahomecare.org

• Data is encrypted through secure socket layers

• Physician signature may be digital or electronic

• Available date to be announced

Trac Medical Soultions

CareCert
tracmed.com

• Uses secure PKI Web server

• Integrates AuthentiDate (electronic content authentication technology)

• Uses a digital hashing code that provides a creation trail for audit and review purposes

• Has the potential for additional medical forms

• In pilot stage