Provider Advisory Groups

Welcome and Introduction
Lori Langevin called the meeting to order at 9:00 am, and thanked everyone for taking the time to participate in the 4^th quarter meeting.

Review of April 22, 2005 meeting minutes
Review of the prior minutes was noted. No comments or changes were suggested. The minutes were approved as written. CMS approved the minutes and they were very pleased with the group’s feedback and your active participation. Our goal as the Fiscal Intermediary is to continue to provide timely, useful and relevant educational opportunities for our providers.

• SNF Advisory Group meeting with Hospital Advisory Group
  This agenda item and suggestion was a request made by the hospital advisory group.

The hospital advisory group felt very strongly that a meeting of the two groups would bring about a better understanding of what each group needs more educational efforts focused on. Also both groups agreed that a combined meeting would help each group to understand the other group’s needs and billing situations. It was agreed upon by both groups to have the meeting in between the hospital and SNF meeting.

The meeting between both groups began at approximately 10:20 am and ended at approximately 12:00 pm. The meeting began by everyone introducing themselves and the facility that they are representing. Lori advised that this is the opportunity for both groups to express their concerns and suggestions for improvement.

Lori advised that the only topic for discussion that was sent for this meeting was by Landmark Medical Center concerning Medlearn Matter MM3592 http://www.cms.hhs.gov/medlearn/matters/mmarticles/2004/MM3592.pdf .

“Skilled Nursing Facility (SNF) Consolidated Billing Service Furnished Under an "Arrangement" with an Outside Entity Revised: 2/8/2005”

This article is a clarification regarding SNF Consolidated Billing; which has been a challenge for all of us.

Lori invited the members to share their concerns and comments.

SNF Advisory Group Comments:
We understand the concept of consolidated billing but sometimes the hospital will send bills that we do not feel that we are responsible to pay. Also, the hospital will make several calls to our SNF but with different people calling so a contact person would be nice to have.

Lori Responded:
My best advice on this issue is to make sure the services that you are being billed are your responsibility. SNF Consolidated Billing guidelines are updated and changed on a quarterly basis, therefore you need to check the CMS website on these annual updates. As far as having once contact person, how do the hospitals feel about sending us a contact name that we can send to the nursing homes so that when a consolidated billing issue arises, they will have a direct contact name and telephone number.

Hospital Advisory Group Comments:
This would be a good idea for us too, so that the correct person at the hospital is handling the inquiry.

Lori Responded:
Since all agree, the hospitals can send their contact information to me for SNF Consolidated Billing issues and I can forward to the SNF group.

SNF Advisory Group Comment:
The hospitals do not send the correct information to us for admitting purposes.

Lori Responded:
This will be a great topic to discuss next as the hospitals also feel that they do not always

receive the information that they need from the SNFs.

Hospital Advisory Group Comment:
Yes, this is true and sometimes a diagnosis code is missing along with the facility name.

SNFs and Hospitals Group Comments:
After a lengthy discussion on this issue, all agreed that a continuity form should be submitted on the patient when they leave a SNF or Hospital to go to another facility. This form should include:

• A demographic sheet
• Insurance information
• Diagnosis of patient
• Facility name

Hospital Advisory Group Suggestion:
This should be included at the Fundamental Workshops.

Lori Responded:
Great Idea. If there are not any other issues that need to be discussed, the hospital group can Be on their way. Should we plan to meet together at least once per fiscal year?

SNFs and Hospitals Group Comments:
All agreed that would be a good idea.

SNF Advisory Group Comment:
If a patient has to leave our facility to go to the hospital for emergency services but they are in observation for over 48 hours, can we discharge them. Also, why do we have to report the patient on a LOA (leave of absence) when they have not been out of the facility for 24 hours.

We need more education on this.

Lori Responded:
You should not discharge the patient from the SNF because they were not admitted. Also, per the Medicare regulations a LOA has to reported at bed check, which is at midnight regardless of whether the patient was gone for 24 hours. Medicare follows the midnight rule. This educational matter was discussed at our SNF Fundamentals Workshop, which was yesterday (7/21/05).

SNF Advisory Group Comment:
Will CMS ever decide to use observation days toward the 3-day qualifying stay for SNF reimbursement?

Lori Responded:
I will forward some information pertaining to this subject matter and also on observation hours with the meeting minutes.

Requested information:
Override of Medicare System Edit for Observation Services ...
... Effective Date: April 1, 2005 Implementation Date: April 4, 2005 Override of Medicare
System Edit for Observation Services Exceeding 48 Hours Provider Types ...
www.cms.hhs.gov/medlearn/matters/mmarticles/2005/MM3311.pdf -

CMS Manual System
... 120 Date: OCTOBER 22, 2004 CHANGE REQUEST 3311 SUBJECT: Override of Common Working File (CWF) Edit for Observation Services Exceeding 48 Hours I. SUMMARY OF ...
www.cms.hhs.gov/manuals/pm_trans/R120OTN.pdf

Reminder of the Required Three-day Hospital Stay for SNF ...
... of this hospital stay cannot include the day of discharge, and moreover cannot
count any Emergency Department or other outpatient observation care in the ...
http://www.cms.hhs.gov/medlearn/matters/mmarticles/2004/SE0403.pdf

Follow up to SNF Consolidated billing ~ Patient is in the ER over the midnight hour

• Lori wanted to share with members the updates received from the Kansas CMS office. The patient leaves the nursing homes and goes to the emergency room, thus the SNF needs to bill Leave of Absence (LOA). It is very important to understand that the only way that you are going to receive reimbursement for related emergency room services after midnight, such as lab tests, x-rays or other diagnostic test, is to use the same line item date as you did for the emergency room code (revenue code 045X).
• I understand that your feedback on this particularly issues is that you do not want to report this way due to compliance reasons. I have done extensive research on examples of these claims involving ER services after midnight. Although a CMS representative from the Texas office advised the FI that the OCE (outpatient code editor) can handle multiples dates of services, which it can, that they were not taking into account that SNF consolidated billing issues are involved with the hospital services. The information given was that you should be able to bill the second day of services and be paid accordingly. This is not the case and FISS will reject the second date. We have advised CMS, per your input, that a MedLearn Matters article to state that would be a great reference for our hospitals.

Response from Advisory Group Member:
Are you saying that the only way that claim go through is to use the same ER date?

Lori responded:
You are absolutely correct. This is the only workaround that CMS has suggested so that you can be reimbursed for your services.

Suggestion from Advisory Group Member:
What if we continue to bill claims with the two days of services and when we get denied, the FI could manually make an adjustment so that a payment for the second day is made. Also, do you have something in writing from CMS?

Lori Responded:
No, FISS will not pay the second day because the patient is being reported back to the SNF so your claim falls into an overlap of services. Even if we were able to manually make changes and tested, down the row every 30 days CWF test program compare the SNF claims with the hospital and it is when you see the automatically take back. I certainly understand from a compliance point of view that you need to report the actual date of service. However because of FISS capabilities this is the only work around that CMS has offered. As far as CMS stating this in writing, we were referred to the OPPS manual, where it stated to use the same line item. If you look up the manual, the billing section does state about having the same day of service, however it does not mention a SNF claim being involved. I have sent some examples to an associate in the Texas CMS office, who I originally received the information from so that she could see the situation that you encounter.

Greg Responded:
This concern will be reflected in the minutes of this meeting, which CMS will review.

Suggestion from Advisory Group Member:
Sometimes it is difficult to find out information regarding the SNF claim that overlaps our claim. Some phone reps will tell you the name of the SNF. Do you have any ideas that would help us when submitting our claims?

Lori Responded:
You could add some information in the remarks section on Page 4 of FISS DDE. You could also utilize this page to indicate the reason that services that were rendered after midnight are billed with the same date as the emergency room service.

Part A Updates ~ Upcoming Hospital Workshops

• Fundamental & Updates. Lori informed the members that yesterday, Thursday July 21, we had the first Part A Fundamentals of Medicare for Skilled Nursing Facilities. The workshop went very well. We had twelve attendees from different facilities attend and they were very pleased with the material discussed.

We will have the first Part A Fundamentals of Medicare for Hospital Facilities on August 25, 2005. Topics such as UB-92 claim form filing, appeal process, FISS DDE and website resources will be discussed. It is very important to stress that this workshop has basic Medicare information and will be very helpful for your new staff. Lori encouraged the members for ideas or suggestions that they would like to be discussed in these meetings. No comments were received at this time.

• Website Navigation.

We also are offering Part A Navigating the RI Medicare Website Workshop, which is targeted to small groups (less than 25 Full time employees). CMS has instructed Medicare contractors to concentrate on these small groups to ensure they are aware of Medicare updates and changes. We plan to schedule this workshop in September 2005. Hopefully, by September will be able to do a live presentation. Please, check our website for upcoming workshop at: http://www.rimedicare.com/provider/events/default.asp

Lori asked the members for any ideas or recommendations that would like to share with us.

Suggestion from Advisory Group Member:
Although the RI Medicare website has very useful information, it is not always user- friendly. I

think it would be a good idea to have more specific links to specific topics.

Lori Responded:
We are working on the Part A website section and plan to add some links that directly links you to the requested information. Also, you can join our list-server and you will receive updates and changes. This is the quickest way to receive Medicare updates.

Suggestion from Advisory Group Member:
Is there any way to get updates by e-mail about EDI problems/issue?

Lori Responded:
Usually as soon as we have the details of any problems, there is an announcement on a pop-up window on our website. I will send an email to the whole group, which is the quickest way to communicate the problem. However, sometimes this is just not possible.

Greg responded: The EDI section on our website just added a portion exclusively related to EDI problems. In the meantime, if you have any suggestions that will help to improve this communication process, please feel free to send to our attention.

Does anybody have any comments or suggestions? No comments were received.

• Ask the Contractor.

The next call will be August 24, 2005 from 10:00 am to 11:00 am. Lori encouraged the members to check our website under events/seminars to verify the call-in number due to unexpected changes in number availability. As soon as the telephone number is confirmed, Lori will send to the group. This conference call will focus on MSP (Medicare Secondary Payer). We are going to have a MSP specialist on the line to address any of your concerns. If time permits, we will open the call to other questions. If you have any ideas or suggestions for this call, please feel free to share with us. Lori reminded the group to also refer to our website for timely updates too. http://www.rimedicare.com/provider/events/eventdel.asp?ID=108

No Suggestions were made at this time.

• FISS Top Ten Reason Codes & Claim Submission Errors
  Lori requested the members for feedback that helps to minimize the claim errors and telephone inquiries.

Does anybody have any other comments or suggestions to reduce these claims submission errors? No comments were received.

Advisory Group Member: Can we get individual reports of the Top Ten Reason Errors. We would like to have more information about our mistakes and develop an improvement process.

Lori Responded: I can share individually with each facility.

Greg Responded: We are sending out letters to providers that are top submitter of the top ten reasons errors; including the claims data that show the number denied. We want to work very closely with these providers in order to reduce their claim errors.

Advisory Group Member: Long Term Care hospitals have a big issue, especially with the use of 74, 76, and 79 Occurrence Span Codes.

Lori Responded: As we have discussed with your facility, the LTCH PPS model does not work you’re your facility as the patient’s stays are just too long to accommodate the FISS system with the limited number of span codes that can be used. Others hospitals do not have this problem. We have brought your special circumstances to the attention of CMS are they are working on this issue with the FI.

Advisory Group Member: Is it possible to obtain more information about overlapping days? For example, would be possible to add a note / information or reasons of the rejection in the remark section.

Lori Responded: You can get the overlapping days involved, but for privacy reasons I do not believe our Customer Service Reps. can release the name of the SNF. I know this is something that you are always going to encounter because the SNF’s submit monthly billing, so obviously your claims are going to get in before their claims get in. The only information that I have found in the CMS website was that span dates and overlapping dates can be given out, but we cannot give out whom that claim come from. However, I will research this further with the manager of the Customer Service Department.

• MSP Cancels.
  Lori advised that the MSP Coordinator wanted me to advise this group that you are not able to cancel any MSP claims online. If you do the claims will suspend and someone internally will have to release the claim. If you have any claims in suspense that you would like to be released; please feel free to contact our Customer Service Dept. and they will submit your request to MSP department. For future canceling of MSP claims, please submit your request in writing to our MSP Department. Please refer to handout.

  Lori asked the group if anybody has experienced a problem with MSP claims but no issues were raised.

• Cert
  As a reminder, AdvanceMed is the contractor for CMS to perform CERT (Comprehensive Error Rate Testing). It is very important that you respond to the medical records request in a timely manner to avoid being a non-responder or subsequently your payment being affected. Now, you are going to have 90 days to respond to their request. For more information on CERT, please refer to the following link: http://www.cms.hhs.gov/CERT/. Also, it is very important to keep informed and Lori encouraged the group to read their monthly Newsletter at: http://www.cms.hhs.gov/CERT/Newsletter--June%20Final.pdf

  Cert Fact Sheet it is an important resources, such background, methodology and instructions, please refer to the following link:
  http://www.cms.hhs.gov/medlearn/certfactsheetv1-3.pdf

• Medical Review ~ Local Coverage Determination (LCD) Timeline Change for Part Providers ~ Cindy Coty, Senior RN
  Cindy informed the members that beginning September 1, 2005 the LCDs posted on the Part A draft LCDs web sites will run one quarter behind the Part B draft LCDs. The purpose is to be more specific to Part A issues and hopefully receive more comments from our Part A providers. Therefore, the LCD / Part B will be open for comments May 1, 2005 and for Part A will be open for comments September 1, 2005.

• Open Discussion ~ Rick Hoover-CMS Boston Regional Office – Drugs Benefits Update

A handout was passed out related to the Medicare Drugs Benefits. The package includes:

1. Medicare Prescription Drug Coverage. This information is designed to anybody who is interested basically in the state of Rhode Island. For those of you who do not know, SHIP is the organization that helps senior citizens understand health care options.
2. Important Dates for people with Medicare for 2005 and 2006. This is a calendar with the major implementation dates for the Medicare Drugs Benefits.
3. Cost Sharing and Extra Help. This is an explanation of the standard benefits, premium, and co-payments.
4. PowerPoint Presentation. Used in organizations to present the Drug Benefits Program. This presentation give a powerful idea about the benefits covered, dateline availability, low income help, retiree drug coverage, facts to make a choice, strategies considerations, bridge gap and contact information for additional information.

This information can be reproduced and then display in waiting rooms, reception areas or discharge rooms. These benefits are the most drastic changes that have happened since the conception of Medicare 40 years ago. People need to be aware that this may not be for them and it depends on what they have other retirement benefits. For those, who truly are going to suffer catastrophic consequences for not having drugs coverage, this benefit will be helpful. Information regarding drug benefit sponsors and management care will be released in September 2005. Medicaid recipient are going to be automatically enrolled, if they did not join on time. Lastly, we are asking that everyone convey this information to any Medicare beneficiary that you may have a contact with. We want to invite our provider to download valuable information from CMS website and make available to their patients, family or friends.

Please refer to the following link:

Also discussed during open discussion was Medlearn Matter SE0528 ~ article pertaining to NPI

and MM 3440 on mandatory electronic claim submission. Lori advised members to read these

articles, if they have not done so and advise on suggestions for educational efforts.

Suggestion from Advisory Member: To incorporate in Medicare workshops.

ACTION ITEMS:

• Can Medicare release the name of a nursing home that a hospital has an overlap claim with? Lori advised, per CMS regulations that only the span of dates can be given and that the hospital should be aware of where that patient came from. Lori will follow-up with the Customer Service Manager on the protocol that they follow.

ANSWER: According to the Desk Disclosure Reference, approved by CMS, that our call center (Customer Service) abides by, they can release a name of another provider as long as both providers have a relationship with the beneficiary and the purpose is to facilitate a payment. Our Customer Service Dept. has been reminded of this information so that consistent information is being released to our providers.

• Hospitals need to send Lori Langevin their contact information for SNF Consolidated Billing.
• Do you offer any way to recognize HMO out of state plans? Lori will check with Customer Service Department.

ANSWER: According to the Desk Disclosure Reference, approved by CMS, that our call center (Customer Service) abides by, they are not allowed to give providers the name of the HMO plan. Providers must get this information from the beneficiary or their representative. Our Customer Service Dept. has been reminded of this information so that consistent information is being released to our providers. If this information should change, we will inform you.

Schedule next meeting
The next meeting will be held on Friday, October 21, 2005 at 9:00am here at the Warwick Public Library. We are trying to accommodate teleconferencing, which this facility is not capable of. We will post and email any changes to the place of the next meeting.

No further recommendations were received from the attending members. The facilitator thanked the members for their feedback and participation. The meeting adjourned at 12:00 noon.

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