Anesthesia Network, UAMS-FGP, UAMS/MCPG Compliance, AR Chiropractic Society, Physical Therapy Association, AR Medical Society, AR Occupational Health Association, Health Financial Management Association, AdvanceMed, AR Physical Therapy Association, AR Ambulance Association, AR Chiropractic Association, AR Optometric Association, Professional Billing and Consulting, AR Anesthesia Network, Arkansas Ambulance Association

Arkansas Blue Cross and Blue Shield Staff
Pat Bonnette, Senior Medicare Services, Technical Support Specialist
Tanya Brooks, Professional Services
Kristi Buckholz, Network Development Representative
Pat Clements, Network Development Representative
Connie Cogshell, Network Development Representative
Rhonda Cordon, Sr. Hearing Officer, Hearings and Appeals
Gary Eads, Manager Part A and Part B Claims
Greg Hart, Professional Services
Sidney Hayes, MD, Medicare Medical Director
Wanda King, Manager, Medicare Secondary Payor
Barbara McDanel, Director,
Susan Moore, Senior RN, Medical Review
Pam Robinett, Medical Review Audit and Analysis
Sharon Robinson, Supervisor, Medicare Claims
Priscilla Secrest, Supervisor, Medical Review
Geneva VanBuren, Supervisor, Provider Enrollment
Kelly Vaughan, EDI Analyst

The meeting was called to order at 10:04 a.m.

• Greg welcomed everyone to the Medicare Services new location and the floor was open for introductions.

2. Updates – Greg Hart

• CMS Guidelines for the PCOMAG (Provider Communication Advisory Group) (Attachment) - This group was established to help get information out from CMS to various organizations. This Group is tasked to develop and direct the best means to communicate CMS changes and updates as they occur. The charter of this group is to focus our education and communication program for providers. While discussion of problems may help to illustrate areas to focus on, it shouldn’t be our primary focus. The group should be representative of providers who bill under Part B, as well as outside agencies such as Medicaid, Billing Agencies, and Consultants. Currently we utilize the web-site, fax, and email system to send the minutes and any notifications.

• Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (Attachement) – The President signed into law, on December 8, 2003, DIMA, which is the Drug Improvement and Modernization Act. This law has many portions and we will publicize the implementation guidelines as they are developed by CMS. Some of the parts that have been released include an increase of 1.5% in the conversion factor of the Physician Fee Schedule.

• Provider Relations – A letter will be mailed concerning Provider Relations Transition (Attachment). This is part of ABCBS initiative to form a separate Medicare company through a process called Novation, CMS have had us working to separate Medicare from the Private side and the first phase has been to move all Medicare staff into one location. We have separated all areas except Provider Relations and this is the transition we have begun. We now have three representatives that will be strictly dedicated to Medicare, and they are, Connie Cogshell, Kristi Buckholz, and Pat Clements. The representatives will function as a team and they will not be assigned to regions. Since we will only have three representatives, we are asking that your first line of communication start with our customer service department. The customer service department will then forward any referrals on to the Provider Representatives. One of the things we are doing to help us work closer is the Provider Representatives are attending the customer service trainings. We are finalizing our workshop schedule and we have decided to conduct the Medicare portion during the mornings and ABCBS portion during the afternoons.

• On the crossover claims, CMS is going to a national contract of crossover claims based on Provider IDs. Provider IDs are similar to the MediGap Inkey numbers, which will be the key to getting the claims crossed over. This goes into effect October 1, 2004. The contracts with complimentary insurances will be based on the eligibility tapes that they provide and the insurance that they cross to will be responsible for resolving the issues. We have worked several years to resolve some of the crossover issues. Please pay close attention to your upcoming newsletters for updates.

• In the past there has been a 90 day grace period for new codes. CMS is eliminating this grace period. It will be applied based on the day of service. The use of 2005 ICD-9 codes will go in effect October 1, 2004 and 2005 CPT codes will go in effect January 1, 2005. CMS Transmittals 89 and 95.

• Sharon presented a handout that list things that the claim specialists are seeing with paper and electronic claims that are causing them to be denied or delayed. With the electronic claims we are still receiving a lot of claims with W, and Y modifiers. These modifiers are invalid because they are level III HCPCS codes that were eliminated as a result of HIPAA. They are informational modifiers used on ambulance claims. Effective January 1, 2004, these modifiers were no longer valid.

• We are also seeing ambulance providers who are not submitting the origin or destination. This ruling was effective April 1, 2002. The origin and destination modifier is required. When we changed from the NSF format to the ANSI4010 format it decreased the space used for ambulance when you have the ambulance record attached. There is space for the comment which allows 80-bite per line. Providers can give us additional information. Providers have complained that their payments are slow and one of the things that are causing this is that we must contact the provider for more information and develop the claim. We need you to make sure that you include the name of the hospital the patient is transported from and the name of the hospital that the patient is being transported to. Medicare will not pay for a patient to go from a larger hospital to a smaller hospital. You will need to enter this in the comment field.

• A high volume of claims submitted by physicians come in that receive an edit that tells us the provider number is not linked. In Arkansas, when there is a clinic involved and the individual performing provider, we have to link that provider number and make that provider number on the detail line a 9-digit number. We went to the MCS system in May 1998; prior to MCS our system linked it for us.

• We could not get them to do this on the new system and prior to the ANSI format all providers were submitting them correctly. Just to give you an idea of how many claims we are receiving with this edit, I have listed some statistics for just this past week.

2/10/04 15,007 Claims received an edit that the provider number is not linked
2/11/04 15,878 Claims received an edit that the provider number is not linked
2/12/04 7,803 Claims received an edit that the provider number is not linked
2/16/04 12,450 Claims received an edit that the provider number is not linked
2/17/04 14,791 Claims received an edit that the provider number is not linked

• Kelly stated that on a daily basis we get anywhere from 25,000 to 30,000 claims a day and this is over half of the amount of claims received that are stopped due to this edit. A representative asked what the providers get back to inform them of this edit. Sharon stated that we fix the problem ourselves but we are working on educating the provider so that the claims will go through properly. When we have to fix these claims it is causing a delay. The number should be listed as the Individual PIN and then the Clinic/Group Billing number. (Example: 5MXXXCXXX)

• A representative asked how we are relaying this information to the clinics. Currently we have contacted a small percentage of the providers by telephone. It was suggested we send back an electronic message but we don’t have the capability through the AHIN or payment systems. Notification was sent out when we first went to the MCS system in 1998 but we didn’t deny claims.

• Sharon stated that she have asked Geneva Vanburen from Provider Enrollment, when sending out the letters setting up new providers, to send the 5-digit number indicating clinic and the 5-digit number indicating the performing provider within that clinic, with instructions on the correct way to bill. If the provider is going to be working in that clinic go ahead and link the numbers for the providers.

• In Box 33 you will indicate the group number if there is a performing provider within that group on item 24K, link the provider numbers there. On 24K on paper claims you still want to put a 9-digit number there. If there is a clinic the billing provider number will go in the group field in Box 33. Greg stated that we will make sure this is included in the workshops. We will also place this on the web-site and in the MedGuide. Providers should start to make the change now as it will become required after adequate notice.

• A representative asked if we had a solution for emergency doctors if they are out sick and another doctor has to fill in. How can they link this provider? Pat Clements stated that a local tandem is when you are replacing a doctor who is on vacation or sick. On the claim you are going to indicate a doctor who is sick with a modifier. You will not link that doctor, only the sick doctor.

• We still have a lot of ambulance providers who are submitting the blue 1491 form and those require special handing especially since we have gone to OCR. For those providers we are advising them to submit them on a 1500. We have a lot of them submitting handwritten claims which require special handling also. For OCR purposes, because of the way the claims are being sent, we are asking that you do not use a dot matrix printer but use a laser printer. Make sure the claims are aligned. On diagnosis pointers, you can only put 4 in item 21 and then for the reference in 24E it asked that you reference the diagnosis. It’s good if you only reference the primary one. The reason being is that eventually they are looking at going consolidated. Greg stated that during the 2003 workshops we told them to only use the primary.

• We have been receiving a lot of invalid Medicare numbers and as a courtesy we go out and look the numbers up. It would be good to advise everyone to make sure they get a copy of the patient's Medicare card. Sometimes the number may change. We sent out a lot of ADS letters and we are asking that you respond as soon as possible. You have 45 days to respond and if not our system will automatically deny those claims.

• When you indicate in item 28 what the amount of the other insurance company paid, we in the past removed the information but that’s altering the claim and now before we take it out we are sending development letters out asking who paid.

4. Medicare Secondary Payor (MSP) – Wanda King

• Wanda King is the new Manager for MSP. We have been working on the backlog and as of 2/13/04 we have Arkansas Part B paper claims at 1,123 and Arkansas Part B EMC claims at 1,289. Arkansas Part A paper claims at 1,258.

• Greg had sent us a question asking how many paper claims versus EMC claims and MSP claims we receive daily. As of 2/103/04 we have 228 paper claims versus 638 EMC claims. Greg mentioned that the submission of claims through EMC will be included in our provider workshops. Sharon stated that one of the problems with MSP claims is that they are putting the amount of money that the other insurance company pays in item 29 for the paid amount which has caused us to develop quite a bit on paper claims. We want to verify if this is the amount paid by the patient or by a primary insurance. Wanda passed out a listing of helpful web-sites for MSP (Handout).

5. Medicare Provider Services – Pat Bonnette

• Here is a little information from our Provider Inquiry Report form Nov 03 to Jan 04

Auto Response Unit (ARU) 25,076
Customer Service Calls 18,000
Total of Inquiries 43,076

• Reviews

• Eligibility issues: When they call us for eligibility information from the provider we will need to have the following (Handout Attached):
  • We must have the last name and the first initial exactly as it appears.
  • Exact Date of Birth
  • Correct HIC Number and their Sex

• Once this information is given we can then give you the eligibility information. We can give you the following information:

• The ABN entitlement and termination dates
• We will tell you if the deductible has been met for current or prior years
• HMO Information as we have it
• MSP Activity
• Home Health start and end dates

• Greg stated that this information was listed in one of the Change Requests (CR2566) through CMS web-site. Eligibility information is also available in the ANSI transaction 270 & 271.

• Greg has passed out a claims report that we will go over. The Arkansas Reasons for Provider Appeals show gross numbers of reasons for appeals.

The Top Three Reasons

• Diagnosis Inquiry
• Global period/postop visit
• Modifiers (excluding global)

• A representative asked if we could get this report more specific to our specialty. Greg stated that we could get the same information broken down by a specialty code. We can’t break it out by the reasons within that, whether it was a diagnosis code or medical review. We can, for Anesthesia practices for instance, put your top reasons for requesting a review. It can be done by specialty and by group. If it’s by a single provider, then we need a request from that provider and the information is mailed to the provider.

• A representative stated that we need something that we can see that will show us where we are making our errors or where we need to change what we are doing. Greg stated that during the workshops we try to show some of the data analysis, but it is a broad spectrum and not provider specific though it has been specialty specific at our specialty workshops. On our web-site under the Provider section there is a tool for Data Analysis. Also, the Comparative Billing Reports are available on a request basis, which primarily talks about codes billed and it does not get into these reasons.

• A representative asked if we could have the report linked to the web-site and the providers could query the report. Greg stated that we have been looking into this but wasn’t sure if this could be added at this time. Greg stated that at the next meeting he will bring a progress report on obtaining this information and also any specialty specific information.

• CMS continues to put in their budget a request to charge for duplicate claims and unprocessable claims. It has been in several budgets but they have never said go fourth. A representative asked if ABCBS is developing a system so when claims get hung up in their system they will be able to identify them. Greg stated that they are getting the development letters out quicker to help resolve this issue

• A representative commented on how well customer service has been responding to his issues. He stated that they are very friendly and eager to assist in anyway they can. He just wanted to say thanks.

• Priscilla stated that she constantly has requests to adjust claims. She is not able to adjust claims that are denied and are closed claims. No claim can be reopened or altered by the Medical Review Department in the system, it has to go into a medical review process.

• A representative had a question about the 98942 billing code expanding into box 19 of the 1500 form. Priscilla stated that you still need to do the expansion to include all primary diagnosis codes and then carry secondary diagnosis codes into box on the paper claim and on the additional comment field for an electronic submission

• Dr. Hayes stated that Local Medical Review Policy (LMRP) has changed to Local Coverage Determination (LCD) and this came about because of the Benefit Improvement and Protection Act that came about in 2001. A few things that will not be moved into this format are coding guidelines, benefit categories. We have to look at each one of our policies to look at all the coding guidelines to make sure the frequency that are include in the coding guidelines would not be an indication of limitation. If so we will have to move it up, or out? The question is will it take the coding guidelines and move them into an article. We have until 2005 to have these consolidations completed. You still have to time to submit your comments.

• Geneva stated that the reason some of you have not received provider numbers is because we have moved to new enrollment system, PECOS (Provider Enrollment, Chain and Ownership System), which requires more information to be entered. It is causing a great delay. We ask that on the application there is a space for an effective date and we strongly recommend that you fill this out. If there is no effective dated entered then we will have to stop, call you and fax the application to you and then wait for you to fax the information back to us. We also need the date of the authorized representative or the delegated official who signs this form. We are now processing applications from the end of November to the first of December. We process about 122 applications per week. This is a system that has quite a few sections that need to be completed. We have four days to get the information in the system. If you do a zip code change we have to key the application as though it was a brand new application into the system.

• A representative asked if it would be beneficial, for something such as that, if we just complete an 855R just to update. Geneva stated that it would be beneficial to do this because on the 855R and you complete the B to get a group number the person that sign the B may not be the same person who sign the R. If you have made a change in your application as far as who signed your original application then you need to let Provider Enrollment know. Geneva stated that the new system was actually an A system that they have added the B system to it and that is why we are having so many problems.

• License renewals are required for Ambulance and CRNAs. It’s every year for Ambulance on every two years for CRNAs. Every two years we receive a listing from the CRNAs credentialing board, which tells us which CRNAs, have not renewed their license.

8. Hearing and Appeals – Rhonda Cordon

• Rhonda stated that we have put in a bid to become a qualified independent contractor or QIC. This will replace the hearing officer level of appeal. All of the requests will go to regional QIC'S across the United States. They will look at the claims. They will consist of a staff of lawyers and nurses, who will see if they can be paid and if not, they will go to the administrative law judge. We don’t know when this will take place. Rhonda also gave a handout that listed the new physical address and the new telephone numbers.

• Al reported that we have not had any widespread fraud issues in Arkansas. He stated that it speaks very highly of the providers in Arkansas. One thing he mentioned was the he knows that providers are busy but it is important for you to make time to review the LMRP. Read the newsletters when they come out and check the CMS web-site.

• Greg stated that we sent out a copy of the CMS electronic wheelchair scam alert to the PCOMAG members.

• OIG Work Plan for 2004 – The Office of Inspector General has released their work plan for next year, this could provide the basis for individual hospital’s compliance programs. The plan is available on their website, www.hhs.gov/oig.

• Kelly stated that on a handwritten claim she is conducting an analysis and we are going to stop accepting handwritten claims. A date has not been set. Kelly is in the process of finding out how many we are receiving and who is doing it. She will be contacting them personally. We will have this published in the newsletter and on the web-site.

• The HIPAA testing started off very slow but has picked up greatly. Currently we have a little over 1,000 people in production for Arkansas Medicare Part B. We have 82 who are currently testing. CMS has stated that as long as they trying to become compliant we are going to work with them.

• We had a lot of problems with WebMD and the majority of these issues have been resolved. If you notice a decrease in your money please contact us immediately. We are having a major problem with clearinghouse downloading the messages and not notifying the providers that their claims have been denied. This has caused an increase in advance payment requests.

• Pat Bonnette stated that she, Greg, and Kelly will get this information out as well to the customer service representatives. Kelly stated that during the testing process you need to send every type of claim that you process because if you pass and go into production having only tested one type of claim and you submit a different type of claim, that claim will be denied.

11. Provider Education – Greg Hart

• Greg passed out the Spring 2004 Workshop schedule (Handout). This will be published on the web-site in the next week. We continue to develop our web based courses; Medicare 101 and Critical Care were recently added to the web-site. We sent out a notice asking for provider review of these courses and apologize for the late notice on the last one.

• We will continue to focus on the best ways to communicate information to our Provider Advisory Group. We would like to encourage you to send your comments to Greg Hart at gphart@arkbluecross.com or Tanya Brooks at tybrooks@arkbluecross.com. Feel free to express your concerns on what you would like to see communicated and also how we can better communicate it to you.

• The next meeting will be May 19, 2004 in the Medicare Services building in North Little Rock, AR.