Direct messaging can reduce Medicare fraud and waste

Direct messaging continues to grow because of its simplicity of use and interoperability via a standardized framework
By Scott Rea
02:27 PM
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Our healthcare system is often too wasteful and inefficient, placing a strain on patient outcomes and the federal budget. The Center for Medicare & Medicaid Services alone is burdened with $50 billion a year just in wrong payments. We're in need of a major step forward using modern technology to provide efficiencies, and Direct messaging is the solution.

In 2011, CMS prescribed the Electronic Submission of Medical Documentation, or esMD, to eliminate the use of fax and snail mail for prior-authorizations and Review Contractor audits and transition them instead to electronic submissions. Yet, four years later just over 7,000 Medicare providers use esMD to submit prior authorization requests, possibly leading to lagging patient care or redundant, unneeded procedures being performed.  

As Baby Boomers retire and increase the number of Medicare patients in the years to come, we have to get more providers to transition to digital health. Fortunately, Direct messaging provides a clear path to onboarding millions of providers nearly overnight.

To-date, more than 1 million Direct addresses exist, and EHR vendors, clinics, hospitals and providers are onboarding almost daily. It's estimated by DirectTrust that its umbrella non-profit collaborative already connects more than half of the entire U.S. healthcare system.

Direct messaging continues to grow because of its simplicity of use and interoperability via a standardized framework put in place by DirectTrust. The benefit of "Direct" is that it supports whatever data formats are already being used by provider EHRs. The focus is on securing the transport method, irrespective of what the message content is. Direct messaging, as prescribed by DirectTrust, utilizes military grade public key infrastructure to give providers, payers, clinics, and all healthcare parties a secure channel to communicate via simple e-mail protocols.

As with e-mail, the sender and the receiver have a Direct Address (a secure healthcare e-mail address), which is where information is either sent from or sent to, depending which side of a transaction the account holder is performing. Providers sending confidential data via Direct can assure that a message's contents will not be revealed except to the intended receiver, guaranteeing that contents are not modified or deleted without either party knowing. Digital certificates assert true identity and encrypt data in transit.

DirectTrust, the largest and fastest-growing community for Direct messaging, includes a vibrant community of vendors, healthcare organizations, and government agencies from across the health IT spectrum working under one common framework of standards that reduces barriers and enhances interoperability.

Providers today typically use health information handlers to submit claims and exchange PHI, as well as for gateway services for esMD submissions. HIHs may be EHR vendors, claim clearinghouses, health information exchanges or release of information vendors. These companies serve an important role in helping providers communicate prior authorizations requests, prove medical services were performed for CMS payment, and other administrative functions.

However, a problem often lies in the lack of secure network connectivity among HIHs and providers. Sometimes, this might be due to technical barriers, whereas other times records are not shared due to proprietary concerns. Regardless of the reason, Direct messaging offers a clear path whereby providers, HIHs and CMS can be connected under the DirectTrust umbrella, which eliminates contractual barriers and compels all vendors to exchange information with each other securely, efficiently and in real time under the DirectTrust standards and framework.  

Direct messaging certificates are not only certified for the DirectTrust community, they also are cross-signed with the Federal Bridge Certificate Authority, the entity that oversees policies and standards for private parties that want to connect with federal agencies. With this dual-trusted certificate in place, providers can use their Direct address to instantly connect via their HIH or directly to CMS to accelerate pre-authorization as well as handle inquiries from Review Contractors and other administrative tasks in real time.

Using Direct messaging as the lead protocol for esMD has the potential to drastically advance healthcare to meet the true promise of digital health. Direct provides a secure, turnkey solution for esMD purposes that doesn't require much, if any, additional expense, since EHR and HIH vendors are already using Direct certificates to achieve various stages of meaningful use. As an additional bonus, CMS has hinted that Direct may play a key role in many future pilots for many areas well beyond MU and esMD.

Our opportunity is now to use Direct messaging to shift the balance in the battle against fraud, waste and abuse and begin to make real savings that could be passed on to Medicare/Medicaid patients and taxpayers at large. With the added advantage that providers could be compensated more quickly for the Medicare/Medicaid services they perform, all parties win with esMD and Direct messaging. Let's not let this opportunity fall by the wayside.