Provider Advisory Groups

1. Merle Francis, Manager Professional Services, LA
2. Greg Hart, Professional Relations, Arkansas Blue Cross
3. Mayo Gilson MD, Medical Director, OK
4. Lori Langevin, Professional Relations, RI Medicare Services
5. Susana M Astros, RI Medicare Services
6. Nancy Porrazzo, RI Medicare Services
7. Andrea Zito RN, RI Medicare Services
8. Carol Kivowitz, RI Medicare Services
9. John Cameron, RI Medicare Services
10. Rick Hoover, CMS Boston Regional Office
11. Maria Figueroa, Butler Hospital
12. Mickey Lourenco, Kent County Hospital
13. Lynne Gauvin, Kent County Hospital
14. Laurie Nelle, Kent County Hospital
15. Carol Foldes, Landmark Medical Center
16. Kathy Petrarca, Women & Infants Hospital
17. Joann Maddox, Women & Infants Hospital
18. Arlene Nimmo, Eleanor Slater Hospital
19. Godiva Laliberte, Eleanor Slater Hospital
20. Tom Thomas, Eleanor Slater Hospital
21. Gertrude Champagne, Lifespan
22. Anna Paschoal, Lifespan
23. Katherine Viveiros, Roger Williams Medical Center
24. Nilda Mendoza, Roger Williams Medical Center
25. Cheryl Adessi, Roger Williams Medical Center
26. Pat Moran, Hospital Association of RI
27. Marc Proto, Saint Joseph Hospital
28. Heather Cole, Saint Joseph Hospital
29. Arleen Palazzo, South County Hospital
30. Lisa Randall, South County Hospital

1. Old Business:

The meeting was called to order at 9:00 am. Lori Langevin invited the audience to introduce themselves, and then she welcomed the members. The minutes from the April 27, 2004 meeting were accepted with no changes. To remind existing members of the purpose of the PCOM Advisory Group, Lori explained that the group meets primarily to assist in the creation, implementation and review of providers/supplier education strategies for future workshops, publications and notices. We need your input to accomplish this task.

2. New Business

Many of the issues / questions that were mentioned at our last meeting were addressed with the meeting minuets that were email to you. However, at the last meeting it was requested for an agenda item that the EPO guidelines be discussed. I have provided this in the package that you received today. Please refer to Medlearn Matters Number: MM2963.

Medlearn Matters is CMS’s new provider information publication which is available on its website at: www.cms.hhs.gov/medlearn/matters/

• Issue Log Call ~ Every other Wednesday (10:00am 1-800-411-0160 passcode # 242199)
  This bi-weekly conference call was scheduled to be conducted on a monthly basis after the next one, which is scheduled for August 4, 2003. However, due to the pending claims issue that was brought to my attention via various emails from the hospitals, I feel that it is necessary, for now, to conduct them bi-weekly. Also, I would like to advise you that we have additional personal working on all these issues in order to resolve each one. However, if any problem arises before our conference call; please feel free to call me, e-mail or fax to my attention and I will be happy to assist you.

• Top 10 FISS Reason Codes/ Top 10 Claim Submission Errors (3^rd Quarter FY04 ~ Handout)

We passed out copies of the last report itemizing and tracking the top 10 reasons codes and claim errors.

• Top 10 reasons for Medicare "A" Provider calls – April, May & June.

1. Verifying Eligibility. Since the conversion this has been the top reason to call. It seems like providers want to verify if they are looking at the right information. When you are in the system, checking eligibility, you need to hit the F8 key three times before you have access to the accurate information.
2. Release Suspended Claims. Sometimes this is related to systems imperfections but other times it is a system function that our internal staff has to review the claim and release it from suspense, just as we had to in the APASS system. We are tracking all the suspended claim locations that are over 30 days so that we can give you accurate feedback.
3. Claim Denial. The numbers are not too high, considering not all providers file electronic claims and many nursing homes are not on FISS DDE.

• Top 10 reason (RSN) by # of Claims in error – April, May & June

• FISS FAQ (Handout)
  We submitted these sheets by mail to all of you, and also you can find on our website www.rimedicare.com. If you have any concern / suggestion or questions feel free to send me by mail, e-mail or fax in order to update this FAQ.

• FISS DDE ~ Locations of pending claims
  I received an update location / status list from Joanne Hernandez; some are Medical Review locations and have to go through certain processes. There are some claims statuses that our internal staff are working to resolve. For example:

• SB90F0- SB90F4, you are not able to touch
• or do something with these statuses.
• SM’s series. These locations are when claims initially come in and we have to put into batch.
• The system has an average of 70,000 different reasons codes, and some still have messages that need updating. We are working accordingly to the priority of each reason code.
• Does anybody have any location / status that would like to share with me?
  • Carol from Landmark Medical Center. Some pending claims are in status SMMENTAL, SMHOSP, MNREM, MSPA1, SM9011, SM90AW & SB02R4. I will track these locations on the current Part A Issue Log to ensure follow-up is completed. Please report claim locations that pending over 30 days. The claims supervisor is working with Arkansas representatives on resolving these issues.
• Long Term Care Hospital PPS (LTCH PPS) claim problems. We do not have a contact person in Arkansas, since they do not have any LTCH; but I have a contact in Connecticut that may be able to assist. Also, Kelly Graichen from our claims department and I are working to resolve these issues. It appears to be a pricing problem with FISS for LTCH PPS claims.
• If you have any claims issues feel free to fax or e-mail to my attention and I will forward to Joann Hernandez’s Department to resolve your concern. As you know I do not process claims, but I want to be aware and track the problems for future educational information to our providers.
• As a reminder, any issue that you submit to our attention, we will notify the respective provider by phone and many times by e-mail.

2. RI Medical Review Issues ~ Andrea Zito, RN

1.) LMRP Updates

There is a draft policy concerning Physical Therapy that is still in the comment period that should be reviewed by all concerned parties.  It can be read at the web-site and there is a link for comments.

2.) Lab NCD Claims

The web-site has a new area for Medical Review. It will contain a list of the new probes with a link to the information to which it refers (NCD, Local Coverage Decision).  It will also have the directions that will no longer be in the policies when they are converted from LMRPs to LCDs.

• Reminder on proper diagnosis coding

Epogen’s Review.

There was a concern that was raised that there are no specifics as regards to the cause of the denials.  I explained that first that any review that is not automated always has a reason for the individual denial listed in the comment section.  I referred to two guidelines that were published on the web-site last year as to how the review is set up.  I explained that the screen is partially automated.  If there are no correct diagnoses the claim will automatically deny for not medically necessary.  If the claim has the correct diagnoses it will automatically pay.  If there is only a partial grouping of the diagnoses then it will suspend for review. I said that I was aware of some problem with the V codes and the description, and after discussion it would be addressed by Dr. Gilson.  In addition I would have the two old guidelines attached to the minutes and have them go out on the web.  Dr. Gilson said that the perhaps the Arkansas policy on Epogen could be implemented soon as one of the new LCDs to be address at the next CAC meeting.

Dr. Mayo Gilson explained the procedures and purposes of CAC meeting, such as follow:

• All policies are posted on our website for comments prior to this meeting
• The Contractor Advisory Committee meeting occurs through a public and open process.
• The Contractor Medical Director will allow any interested parties, such physicians, providers, vendors, beneficiaries; to make presentation of information related to draft policies, also written comments are equal considerate at the meeting.

Rick Hoover from CMS Boston Regional Office has been very involved in the Medicare Modernization Act and all the future related to this Act, such the drug discount card. He motivated the member for any feedback about this Act and feel free to call him at 1-617-565-1258.

3. Part A Updates – Lori Langevin

• Appeals to be called Redeterminations ~ Effective 10/1/04 (MRN) Medicare Redetermination Notice – 60 days to complete
  Effective 10/1/04, the first level appeals will be called "Redetermination". Medicare will have 60 days to complete, then the notification letter MRN-Medicare Redetermination Notice will be sent out. Notification letter was sent out; feel free to look up the information in the following link:
  http://www.cms.hhs.gov/medlearn/matters/mmarticles/2004/MM2620.pdf

• Elimination of 90-day grace period for discontinued ICD.9 codes (Effective 10/1/04)
  Medicare systems will begin enforcing HIPAA standards on October 1, 2004, requiring that IDC-9 codes submitted on claims must be valid at the time the service is provided. As a result, the 90 day grace period is discontinued. Notification letter was sent out; feel free to look up the information in the following link:
  http://www.cms.hhs.gov/medlearn/matters/mmarticles/2004/MM3094.pdf

• Elimination of 90-day grace periods on discontinued HCPCs codes (Effective 1/1/05).
  Medicare will not longer have a 90 day grace period to use discontinued HCPS codes for services rendered in the first 90 days of the year. Notification letter was sent out; feel free to look up the information in the following link:
  http://www.cms.hhs.gov/medlearn/matters/mmarticles/2004/MM3093.pdf

This is the most updated version of Medicare UB-92 revenue & other codes and very useful tool for all of you. This sheet does not include the new patient relationship codes; however I have created this list:

3.) Coding on Medicare Claims for Aranesp and Epogen ~ Medlearn Matters Number: MM2963 (Handout)

This is the guideline for the administration of Aranesp and EPO for your ESRD patients on or after January 01, 2004. If you have any questions regarding this issue please let me know, otherwise feel free to look up the information in the following links:
http://www.cms.hhs.gov/medlearn/matters/mmarticles/2004/MM2963.pdf (MedLearnMatters)
http://www.cms.hhs.gov/mcd/indexes.asp (Medicare Coverage Database)

Andrea Zito, RN pointed out that these coding guidelines was sent out 03/28/2003, then clarified on 05/16/2003 by Dr Staples and also was posted in our website, but we will forward to your attention with the minutes of this meeting.

4. CERT ~ Provider Focus Group for CERT process - (Response Required handout)

A Comprehensive Error Rate Testing (CERT) Program has been implemented by the Center for Medicare & Medicaid Services (CMS). AdvanceMed, the CERT contractor, review the efficiency of the clinical process. It is very imperative to response to their medical records request in order to avoid the collection of dollars previously paid. You will receive the request in this order:

1. First request letter. Randomly selected, attach you can find a copy of the initial letter submitted for AdvanceMed.
2. Second request letter, 20 days after the initial letter.
3. Third request letter, 30 days after the initial letter.
4. Final letter, 45 days after the initial letter.

It is a very critical situation and it is a mandatory regulation from CMS and as a contractor we have to comply in an accurate manner. Non-responders contribute significantly to the Medicare Fee-For-Service error rate. Therefore, it is important to submit medical records upon request in a timely manner.

5. ABN’s ~ Advance Beneficiary Notice – Guidelines (ABN & G’s modifiers was passed out)

   Lori clarified that Medicare pays for Pap tests and pelvis exams (and clinical breast exam) for all women once every 24 months, but this test will allow/paid once every 12 months if you have a high risk or an abnormal tests in the past 36 months, means the diagnostic that you submitted in your claims will determined if the claims has to be paid or denied. Pap and Mammography tests when performed outside the Medicare frequency would not be considered excluded Medicare benefits and the GY modifier would not be appropriate.

6. Audit & Reimbursement ~ Carol Kivowitz
   • 838 Reporting

   This is to remind all providers of the due dates for the CMS 838 balances reporting. June 30^th report is due July 30^th. We are distributing a schedule with all of the due dates for this report. This report can be hand delivered or mailed, but no faxes will be accepted.

   • Mailing address – R E M I N D E R (Handout was passed out)

   We would like to remind all providers of the mailing of provider Audit and Reimbursement.
    

7. Open Discussion
   • Website ~ Medicare updates daily

   Medicare’s website is updated on a daily basis and we like to encourage the audience to use more frequently in order to receive the most recent changes, deletions and updated Medicare information. Also, we have free-charges courses for which you can receive credits.

   Carol Foldes ~ Landmark Medical Center. We have many problems with credentialing, so many delays and returns.

   Merle Francis: We have some kind of delay due the fact that our providers did not submit the complete information, or did not sign the applications or they sent the wrong data. So far we have almost 400 applications in this status, which means incomplete information received. However, in order to eliminate this problem we have a full time employee dedicated to call and inform these providers about the missing information. In addition, we are preparing a data analysis of this problem that will help us to develop Provider Enrollment Workshops in the near future.
    

   • HIPAA Updates ~ Reminder on Medlearn Matters articles
     Medlearn Matters Number: MM2981 - http://www.cms.hhs.gov/medlearn/matters/mmarticles/2004/MM2981.pdf
     Medlearn Matters Number: MM3050 - http://www.cms.hhs.gov/medlearn/matters/mmarticles/2004/MM3050.pdf
     Medlearn Matters Number: MM3031 - http://www.cms.hhs.gov/medlearn/matters/mmarticles/2004/MM3031a.pdf
     
     These articles were passed out in our last meeting (4/27/04). We decided to add these articles due the fact that we still receiving questions on these issues
      
8. Next meeting & agenda Items
   To be determined.

• FY05 ~ 1^st Quarter
  Very soon we will submit to your attention the tentative meeting dates for the new fiscal year. We would like to receive your feedback on this matter, because we want all of you to be present.

  Dr. Gilson suggested hosting a meeting for the doctors on the importance of medical documentation for proper Medicare reimbursement. We could use the PCOM meeting to accomplish this task.

• Lori Langevin will send the MSP Questionnaire that Hospitals and SNF's need to complete for each patient with the meeting minutes.  This will also be posted to the RI Medicare website.

• Lori Langevin to add various claim locations where claims are pending for over 30 days to the Part "A" issue log.  (i.e. SMMENTAL, SMHOSP, MNREM, MSPA1, SM9011, SM90AW & SB02R4).  These locations will be tracked so that claims are not pending over 30 days.  
  Completed 8/4/04

• Lori Langevin to verify the hours FISS DDE is available for checking Medicare eligibility.  Currently, the hours of availability for the FISS system is from 6:00 am to 8:00 pm (Mon- Fri) and Saturdays from 7:00am to 2:00pm.

• Lori Langevin to supply a list of the new "Patient Relationship to Insured" codes.
  Completed ~ listed under UB-92 coding sheet.

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