Provider Advisory Groups

Attendees:
Paula Archer, Baird, Kurtz, and Dodson, LLP, Arkansas AAPC, ArHIMA
Brent Beaulieu, Manager, Baird, Kurtz, and Dodson, LLP, Arkansas HFMA
Shannon Clark, CFO, Ashley County Medical Center
Paul Cunningham, Senior Vice President, Arkansas Hospital Association
Doug Gordan, Arkansas Department of Health
Amanda Goodwin, CMS Dallas Regional Office
Pam Kanawyer. CMS Dallas Regional Office
Jimmy Leopard, CEO, Medical Park Hospital
Sharon Martin, Arkansas Department of Health
Ryan Smith, Saint Bernard’s Medical Center
Jason Springs, CEO, HealthPark Hospital
Tom Stickel, Clinical Service Coordinator, Piggott Community Hospital
Pam Stroyanoff, CFO, Saint Vincent’s Infirmary Medical Center
Joe Wewers, CHFP, Mid South Credit Bureau, Arkansas HFMA
Michaelle Wilkins, Controller, Chambers Memorial Hospital

ABCBS Staff:
Tanya Brooks, Provider Education & Training Representative
Pat Clements, Provider Education & Training Representative
Connie Cogshell, Provider Education & Training Representative
Amanda Crosby, Medicare Provider Audit & Reimbursement
Rozetta Harper, Medicare Secondary Payor
Greg Hart, Professional Services
Dr. Sidney Hayes, Medical Director
Linda Lewis, Medicare Part A Claims and Customer Service
Darlene Carr-McDaniel, Medicare Medical Review
Susan Moore, Supervisor, Medicare Medical Review
Sandy Tribble, Medicare Part A Claims and Customer Service
Barbara Oberste, Director Medicare Integrity Programs
Kelly Vaughan, Medicare Systems Analysis

1. Welcome and Introductions – Paul Cunningham

• Paul Cunningham gave opening remarks and welcomed everyone. After introductions, Paul also gave a brief overview of the purpose of this group. 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.

• Greg went over the purpose of the Provider Communications Advisory Group as outlined in the CMS manual (copy attached). The primary focus of this group is to provide input from the provider side on our education and communication program and give us input as to how we can improve. While discussion of specific problems may help to illustrate areas to focus on, the resolution of specific issues is outside the scope of this group. Membership should be a representative of providers who bill under Part A, as well as outside agencies such as Medicaid, Billing Agencies, and Consultants. CMS wants us to reemphasize the purpose of this group to ensure we meet the requirements they have established. The agenda’s format has changed to better reflect this purpose.

3. Provider Education – Greg Hart

• Greg gave an overall summary of the Hospital Workshop held on August 4, 2004 and the Critical Access Hospital Workshop (CAH) held on August 19, 2004. Summaries of the evaluations for both these workshops were discussed.
• The evaluations reflected that the majority of attendees at the hospital workshop were from billing and some of the topics were not of interest to them. While attendees felt the material provided was good, some of the agenda topics were not of primary interest to the majority of attendees. In the past this meeting covered a variety of topics for the various areas represented. It appears that isn’t the best approach. A proposal was discussed to have quarterly hospital sessions with a different focus at each one, such as one just for the billing staff. Survey results from a recent Arkansas Hospital Association survey of all hospitals showed that most were in favor of a change to quarterly topics as well as providing suggestions of topics to cover.
• A representative asked if we will focus on any legal issues specifically for Medicare. Greg stated that generally they always have someone there to discuss any new legal issues. A representative stated that they wanted to see a workshop that looked at time line and deadlines for specific issues, such as, HIPAA, code changes and deductible increases. This area will be looked at to become one of the quarterly sessions.
• We will also look at working with the Arkansas HFMA to address the provider audit and reimbursement issues at one of their meetings so that we are reaching the primary audience for this information. After further discussion the group felt this was a good approach to pursue this year.
• One of the main suggestions at the CAH workshop was conducting the claims and provider audit and reimbursement sessions together to allow for more information on how claims affects the cost report. Greg stated we are working with the Arkansas Department of Health to have a special session for this information.
  • Paul wanted to know what hospital was caught up in the redesignation of MSAs. He was aware of one. He asked if they would still be able to retain their CAH status now that they are in MSA. A representative stated that he has heard of this but could not give a definite answer. Paul stated that they have a year to meet state requirements. A representative stated that you can meet 2 of the 5 requirements outsides of the 35-mile requirement that CMS published when the rules first came out.
• Greg stated that we are working to create a separate Part A section of our website what items of interest would they like to see, such as Provider Audit and Reimbursement items. A representative suggested that we set up a section on our website where if someone has a question and people they can post it and people can respond to it. We would like their feedback on any other areas.

  ACTION ITEM: Greg will look into the feasibility of having an interactive Q&A area on our website.
   

• Greg stated we are planning to conduct a Rural Health Clinic workshop in the late spring of 2005. It will be for both hospital based RHCs as well as freestanding. Becky Peal-Sconce, CMS Dallas Regional Office, has agreed to attend if possible as well as the Medicare contractor for freestanding RHCs. We have also received a request to conduct a workshop on hospital-based ambulance and will be working to schedule this as well. Members were asked for other suggestions for area to cover by workshops.
   
• Greg gave an overview of the Provider Education Strategy for 2005 Workshops:
  1. Hospital Billing Workshop we are looking to the spring of 2005 and will be working with AHA with its agenda.
  2. Critical Access Hospital
  3. Hospital Part A Fundamentals Workshop, this will address the basics of billing on the UB92, Medicare Secondary Payer (MSP), Medicare Medical Review etc. We are looking to April and will be work with AHA
  4. Inpatient Psychiatric Facility PPS Workshop, we are looking to March 2005 and will be working with Provider Audit and Reimbursement in setting up the agenda.

• "Ask The Contractor" Teleconference - Greg discussed that CMS has instructed local carriers to offer providers an opportunity to discuss topics of interest and/or issues that impact all providers via teleconference. Though it is not designed to address individual provider issues, an issue may be addressed if other providers are being impacted. These will be held at least quarterly and will publish an agenda with "hot topics" on the website for both Part B and Part A providers. The first teleconference is scheduled for March 9^th. Part A teleconference 10:00 – 11:00 am followed by Part B teleconference at noon.
• Members discussed topics, format, as well as timing for these calls. A representative stated that an hour may not be enough time to address concerns from statewide provider, and asked if there will be calls for each specific specialty, i.e. Critical Access, Hospital, and SNF Greg indicated the first one will be general and will review how to proceed for upcoming teleconferences.

4. Data Analysis

• Greg explained that one of goals is to reduce the claims errors submission. We utilize internal data analysis as well as data from the Comprehensive Error Rate Testing - CERT Program to help identify claims submission errors as well as providers that should be targeted for education.

• Dr. Hayes stated the ranking of states, providers that send in medical records, Arkansas ranked one of the worst. We have the highest non-response rate for our FI. Discussion followed.
• A representative stated within their facility the problem they see is getting the request to the right individual. Based on how the envelop was address, listing the facility name and address, the mail room does not know who to forward it to. In most cases, it’s routed around, by the time it reaches the correct individual the timeframe to respond has passed. Discussion followed. Suggestions to address these requests to a position and not an individual.
• Barbara Oberste gave an overview on the CERT Program and the FIs responsibility on following up with non-responder providers. Discussion followed. The 855 is checked for the contact and address, in mailing the CERT letters.
• A representative asked if there would be a resource in contacting hospitals who are the "non-responders". It was suggested to place in upcoming provider newsletters/websites as a reminder to respond to AdvanceMed/CERT requests, and utilize AHA Newsletter.

5. Medical Review – Susan Moore – Pre-pay Part A

• Discussed the Part A Web page on the Arkansas Website, requested the committee to review the items and would like feedback on, i.e. Probe Review Process, Edits and Audits, Medical Policy etc. Will also add a SNF page discussing their issues. Susan would like this group to provide feedback on what is currently on the website, and items which should be added, deleted etc.
• Susan gave an overview from the last meeting regarding the IRF Probe and the initial results. Since then there have been changes and identified extensive issues, she is looking to this group for suggestions in getting educational issues out to the provider community.
• Darlene Carr-McDaniel recapped the IRF Probe in reviewing claims. This was a random section of 101 claims, out of the initial review 89 claims were denied, within that number 25% were non-responders. Additionally, we did not receive pieces of requested documents. Letters were mailed to the CFO’s regarding this. The responses reflected systems changes within the facilities which accounted for the requested information not reaching the appropriate individual. This brought to light how the letters are processed within the facility and what process needed to take place from that point. On redeterminations there were 72 claims that were requested, of the 72 claims 22 have been denied, and have 17 with no requests for redeterminations. The total denial rate after this review was 39%. It does look better after the redetermination took place. They still find problem areas of the lack of medical documentation or the admission. This will be their focal point for provider education. With this in mind, there will be two IRF Workshops on February 8 with invitations being mailed and placed on the website. The main focus will be on documentation.
  
  Paul asked if this information will be placed in our Provider Newsletters providing the history and how medical review will proceed with this directive. Susan confirmed the information will be posted on the website and provider newsletter.

6. Audit and Reimbursement – Amanda Crosby

• Amanda addressed the compliance reviews on IRF’s Part A Provider Enrollment which is part of Audit and Reimbursement, will begin this spring to do these reviews. The approach will depend on the percentage of Medicare utilization that each facility has. It appears that every provider has at least 50% Medicare utilization in the IRF that excluded unit within the hospital. This will dedicate how we will go about determining whether the hospital is complies with the percentage rule, starting with the 50% effective with cost reports beginning on or after July 2004. Those providers whose Medicare’s utilization is greater than 50% we will access the data base for Medicare information that will be used. If a provider is below the 50% Medicare utilization we will look at the total claims, and in this case will ask providers for clarification.
• A representative asked what will happen if a facility does not meet those percentages. Amanda stated a Change Request (CR) address’s the action to be taken. Basically, if the facility Medicare utilization is greater than 50% CMS makes the assumption that the Medicare population represents the total population. If it’s below the 50% we will request all records.
• Amanda addressed problems they see with the 855, when facilities have staff changes etc, their area are not being notified. Provider Audit and Reimbursement handles all Part A enrollment, which includes changes to the 855. If a facility has a new administrator, CFO or a new management company we need to be notified by updating the 855. Discussion followed. A reminder, if the signature on the original 855 does not match with the signature on the incoming change, we cannot accept that change until we have a new 855 reflecting the new individual. Amanda stated the entire 855 does not need to be completed, only those sections which address the change. The 855 is available on the website.
• Regarding non-response, in the last meeting, they are beginning a project to update our files our permanent files, by sending letters to the providers, assisting us in updating our files. Will follow up with the non-responders in obtaining this information. She encouraged this group to complete the request when it’s received.
• Paul brought up that the area wages index surveys done in other states; the FI’s were doing more education/details reviews on the information that is submitted under the area wage index. He asked some Little Rock providers if they felt there was a need for this, the general response was no. Amanda stated they are not seeing any serious pattern of problems. If providers feel there is a need for them to include wage index surveys and the completion of those forms and how they are reviewed, this can be something which can be addressed in the workshops.

• Kelly mentioned very little HIPAA testing is going on at this time. All of the Medicare electronic billers are transmitting in the HIPAA complaint format is at 100%. We do receive some paper claims and those billers are being monitored. Kelly is working with these paper billers in setting them up to file electronically.
• Any HIPAA complaint electronic billers who are sending in paper claims are monitored and will be contacted to find out why. Kelly will be working with them.
• 835 Correction Action Plan EDI is devoting a lot of their attention/efforts to all of their trading partners, electronic submitters, who send claims electronically - efforts are under away in providing them an electronic remittance advise – 835. Some of the hospitals currently do the 835, but some are not. EDI is generating their current electronic remit and the new 835; this will allow hospital to test/download these so any issues can be worked through.
• Under the EDI Website there will be new changes making the website user friendly. A more current format. EDI welcomes any comments from this group.
• A representative stated they are having a lot problems with their pass through and MSP claims which are filed paper. The MSP claims will not cross over electronically consistently. Discussion followed.

• Rozetta reviewed the following with the group. The members discussed the best way to get this information out to the providers. It was decided that we will include it in our newsletter as well as on our website.
  • Requesting a claim to be cancelled
  • MSP Provider Initiated Adjustments
  • Submitting a new claim or requesting an MSP adjustment
  • Submitting a Credit Balance report for MSP
  • Determining the amount to place in the MSP amount and value code 44
  • Multiple Insurers
  • Filing Claims for Conditional Payment when the Primary Payer Denied the Claim
  • Filing Claims for Medicare Primary Payment when the Primary Payer applied the Entire allowed amount to the patient’s deductible
  • Time Line for filing a Medicare Secondary Claim
  • Medicare Secondary Payer Processing Guidelines

• Sandy stated there are currently 23 Critical Access Hospitals in Arkansas, with an additional three hospitals looking at going to ACH, 2 in Southwest Arkansas and one in Northwest Arkansas.

9. The meeting was adjourned at 12:10 pm

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