Representatives from:
Arkansas Hospital Association; Medical Park Hospital Hope; North Arkansas Regional Medical Center; St. Bernard's Healthcare; St. Vincent North Rehab Hospital; Chambers Memorial Hospital; St. Vincent Infirmary Medical Center

Amanda Crosby, Manager, Provider Audit and Reimbursement
Theresa Milligan, Director, Medicare Administrative Support
Linda Lewis, Supervisor, Medicare Part A Claims and Customer Service
Charlotte Garlington, Medicare Medical Review, Part A
Bobbye Garner, Director, Medicare Services
Kelley Vaughan, EDI
Kay Werner, Manager, MSP Operations
Sidney Hayes, M.D., CMD
Forrest Wolfe, Manager, Medicare Claims

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1. Arkansas Hospital Association
   
   A representative reviewed the background of PAG and introduced a representative from SVI.
    

2. FISS Crossover Issue - Theresa Milligan reported that in researching issues related to crossover claims it was found that the FISS only crosses the claims to one supplemental insurer based on the first eligibility record it hits. The maintainer of FISS is addressing this issue. However, the fix is not scheduled for release until July. The staff at the Arkansas Data Center has developed a local fix. However, ABCBS has to receive permission from CMS to implement it.
    

3. 2003 Physician Fee Schedule - New HCPCS codes for 2003 will not be payable until 03-01-03. CMS is asking providers not to file claims with the new codes until after 03-01-03. There is a link to the Federal Register, which contains the codes on the AHA Newsletter. Additionally this information is on the AR Medicare web-site.
    
4. Audit and Reimbursement – Amanda Crosby noted that letters have been sent to hospitals regarding the public use files being available. This information will also be on the web-site. Providers have until 02-10-03 to get with Medicare as to any problems - must be received by 02-10 - not postmarked.
   
   Hospital Outliers - CMS has started a project regarding hospital outliers. The FIs are doing analysis of the outliers. For providers meeting certain thresholds, a special audit is required. However, in AR there are no providers, which meet the thresholds. There are several which are on the borderline and we will keep an eye on them and possibly do further analysis. It is a case of charges greatly increasing over the past several years. The information is on CRs 2508 and 2500, which are on the CMS web-site.

   If further review of the claims is needed, then MR will also be involved in reviewing the records. There were significant changes in the CR from the draft to the final - the thresholds were changed and resulted in AR not having any providers involved.

   The wage index information is not available to ABCBS at this time. The public use information is available on the web and must be reviewed by 02-10-03.

   AHA will also put out information about the availability of the public use information. A representative from CMS contacted a representative at Arkansas Hospital Association about a hospital, which had not responded to a questionnaire about the area wage index information for their facility and resulted in the information being excluded from the mix. Amanda Crosby will work with a representative from Arkansas Hospital Association on this particular provider.
    

5. 2003 Update of the Hospital OPPS
   
   Linda Lewis distributed a PM about the 2003 update of the Hospital OPPS. She highlighted several key areas:

• Observation Beds - G0244 is a code about which a lot of providers have questions. This PM clarifies several of the issues. MR is reviewing observation bed claims. The PM explains conditions for additional payments.
• Summary of billing and payment rules for deceased benes
• New G codes - there are a lot of issues and problems with billers understanding the status of these codes
• Modifiers and Pass-thru devices - new codes to be used in 2003 are listed
• HCPCS replacement codes for retiring pass-thrus.
• Summary of pass-thru drugs - there are several issues answered in this PM which have been raised in the past. Specifically, how are drugs that are shared among several patients to be billed and how to handle when there is drug left after the course of treatment.

Paul Cunningham questioned drug billing for transplant patients after the initial dose of immunosuppressive therapy. He had received information from CMS that the facilities must obtain a DMERC ID in order to bill for the subsequent doses of the drugs.

6. General Part A Issues
   • Linda Lewis made available a handout she had prepared to explain the billing procedures for coding outliers.
   • A representative of Arkansas Hospital Association questioned who is responsible for paying for beneficiaries who are in custody of state and local authorities. Linda Lewis will look up the recent information on this issue and provide it for them at a later date. A representative of the Arkansas Hospital Association noted, that they would include the clarification in the AHA Notebook.
   • Forrest Wolfe distributed the Top 25 Reasons for Calls. He asked once again that providers use the Remote for claim status. It does appear that the number of calls for status is decreasing. Kelly Vaughan noted that there are more providers requesting access to the Remote in order to use it for that purpose. There may be some confusion in the providers about how many IDs they can have and the number of terminals in use. Both can be increased. Some providers limit their staff to a certain amount of time to use the remote and are confused about paying for long distance. Kelly clarified that once the provider is connected, the remote disconnects and calls the provider back. Thus, the costs are on the Remote, not the provider.
7. Medicare Secondary Payer (MSP)
   
   Kay Werner had available a fact sheet about the COBC (Coordination of Benefits Contractor) and how to get in touch with them. Kay explained the purpose of the COBC. The COBC (Group Health, Inc. of New York) is the contractor who is responsible for all COB Medicare claims development and determination of liability. They also handle general inquiries and provide assistance to the providers, attorneys, and beneficiaries.

   There have been some issues to develop since the incorporation of this change. The COBC was not initially staffed to handle the workload volume. They are doing much better now.

   CR 2050 is a draft which has to do with multiple (three or more) payers - e.g., a working aged has coverage through employer and then they have a car accident - the group and auto liability must pay first, then Medicare will pay third. Changes to both the Part A and Part B standard processing systems will be required prior to the implementation of this change, which is scheduled to be effective July 2003. These changes will eliminate the manual intervention and processing delays currently required.

   Two issues that Kay wanted to discuss in particular concerned:

   • Phone calls - providers are having trouble getting through to MSP Service Reps using the MSP toll-free line. Training of the Medicare Part B services staff on some general MSP issues has been conducted and effective 12-01, all of the MSP Part B calls were diverted away from the MSP Toll-free line. The diversion of approximately 500 Part B calls in December allowed a larger window of time to respond to Part A inquiries. We are hopeful that this process improvement will continue to result in improved customer service for our Part A providers

   • Backlog of claims in MSP suspense. MSP staff is working to get the backlog down. Extensive training was held with our front-end staff in December to better screen and enter the data on the front end. Our MSP staff is also working overtime now and will continue until the backlog is under control. We are also working toward imaging claims so that they will be available on-line without having to pull the hardcopy. This will speed up our process and allow staff in our other states to help with working the MSP suspense. We are projecting the imaging to begin in February.

   A representative of Arkansas Hospital Association asked about the size of the backlog. Kay noted that MSP Part A suspense is about 6.9% of the aged volume - about 1857 claims as of this week. A representative of St. Vincent North Rehab Hospital asked when the backlog would be under control. Kay noted it is anticipated that the backlog will be under control within the next two months. The suspense was climbing until November, however, with the overtime and training, we are seeing a decrease. A representative of St. Vincent North Rehab Hospital noted that since the Rehab fix went in, their problems have subsided. They did not think that the problems they had experience were MSP.

   Bobbye Garner noted that the COBC could be a small part of the issue now as far as awaiting feedback on the development. Initially, the COBC was a major issue.
    

8. Benefits Integrity
   
   Theresa Milligan reported for Barbara McDanel that the BI contract has been awarded to Advanced Med located in Nashville, TN. They will assume the BI workload for Arkansas Medicare Part A effective March 15, 2003. Staff from Advanced Med will attempt to attend one of the future Hospital PAGs to go over their strategies and goals. ABCBS will still have a minor role in screening calls from the service lines for referral.
    

9. Medical Review
   
   Charlotte Garlington reported on the PROBE reviews. Automated Development Request (ADR) letters are sent out certified mail to the Administrator requesting information within 30 days. ABCBS has been lenient and was allowing several extra weeks to receive the information. One provider waited six months to submit the requested information. We did some education and individual contacts and got this time reduced back down. However, we are seeing an increase in the timeline for getting the information sent back in. Provider management needs to be sure that the staff in the facilities is aware of the timelines and the necessity for getting the information in timely. These requests can be copy intensive. However, we are anticipating CMS coming out with instructions which state that we must stick with the 30-day timeline for obtaining the records. If the records are not submitted timely, then the FI has the option to call the provider or review the information on hand and adjudicate the claim. If this happens the only information MR has at this time is the UB92 and usually a denial is the determination.
   
   Normal ADR’s not Probes
   
    

   A representative of St. Vincent's Infirmary Medical Center (SVI) asked where the records were being sent. SVI now sends theirs directly to MMR. It was also noted that they annotate when the records were sent and how many times they have been sent. SVI has had significant problems with their mail vendor - that contract was terminated and a new vendor has been obtained. A representative from St. Vincent North Rehab noted that they have had the same problem with sending the records numerous times. They are trying to be sure that the records are sent directly to the 10th floor to MMR. Charlotte noted that couriers are delivering the packages - sometimes not all that were supposed to be delivered. A representative form Arkansas Hospital Association noted they had put an article in the AHA Notebook about how to send in records. This is an on-going problem. A representative from North Arkansas Regional Medical Center noted that it had gotten so bad that he started sending the records himself and using certified mail. All parties agreed that the issue is getting better.

   Charlotte noted that the February newsletter would have information about "what to send in when you get an ADR". You should send back the original request. Some people X out information or use a highlighter which makes it impossible to read when we get a copy.

   Charlotte reported on another issue - the FIs are not to request an ABN when we get a condition code 20 with an occurrence code 32 - demand bill. This leaves a problem - if Medicare gets the bill without a modifier to signify which line is to have the waiver of liability ABN applied, then Medicare must deny the full claim because we don't know which line is to be reviewed. The provider can send in the ABN with the claim, but CMS wants to push providers to use the modifiers correctly. In order to get the claim paid once it is denied the provider will have to request an appeal.

   Charlotte stressed that the December Newsletter (page 18) asked for a contact for MR issues. She noted that we have only received information from 10% of the providers. The person should be someone who deals with educational issues, compliance, etc. Charlotte needs the contact to be someone who can go to the various departments within the provider and get the education done and the changes implemented. She usually asks for the compliance person when she has not been provided with a specific person. A representative from Arkansas Hospital Association will include an article in the AHA Notebook.

   Another issue involves some of the providers certified for diabetic education training do not understand the policy and documentation requirements for standards 17, 18, and 19. Charlotte is working with some of the providers based on analysis from the Local Provider Education and Training (LPET) program.

   Charlotte also noted that Medicare is receiving a lot of records, which have not been requested. We may ask for a MRI report and end up getting copies of the Medicare card, notes, etc. We are not allowed to discard these records. This is a problem for the providers copying all the records and us imaging them.

   A problem came up yesterday where a provider called and noted that they had gotten 90 development letters on claims which had already been paid, were already developed, etc. We are checking out this issue to determine what is happening. It appears that the development letters are being recycled back out. Linda Lewis is working with the Claims Analyst to determine what the problem is. Forrest Wolfe noted that the Data Center needs to be involved so that they can get into the loop and track it down.

   Note: Following the PAG meeting, further research of the above problem revealed that this was actually an isolated issue involving only one provider. The provider had contacted the Medicare Part A service area with a list of claims they requested be released. This action resulted in the claims being re-cycled through the Part A FISS system with development letters regenerating.

   Hearings and Appeals

   Theresa Milligan reported that there are no apparent increases in workload or unusual problems in the Part A appeals area at this time.
    

10. EDI and HIPAA
    
     

    Kelly Vaughan reported on the HIPAA testing. We currently have 52 people testing which includes A, B, regular business, vendors, clearinghouses, etc. Of the 52, 29 have passed. Of the 29, SSI, which is Part A, has passed the 837-I claims for 4010 X12. By the end of January, the version will probably be 4010 X12A1. We will not require anyone who has passed the 4010 X12 to retest, but we will encourage retesting. April 23 is he deadline for the HIPAA testing to begin. We are encouraging the providers to get with their vendors to push them to start testing. People are confused about the testing and should stay on their vendors.

    Another issue that has surfaced involves InfoTech Global Inc. There are 18 facilities, which have received a federal grant for HIPAA compliancy. The facilities are being asked by their vendor to pay for the information that ITG is requesting. If you know any facilities (under 50 beds) that are involved with this group, Kelly will work with them.

    A representative of St. Bernard's Hospital noted that they use SSI's software and asked whether the hospital will have to test? Kelly replied that they do not. SSI's software has been cleared for both the uses of the software and as a clearinghouse. Ryan will have to sign a Trading Partner Agreement with ABCBS since they are direct submission.

    Once a provider is cleared for production, the provider must notify ABCBS as to the date they want to go productional on the HIPAA version - no going back once you go to HIPAA. Coordination of the going live date is critical. All testing must be completed and passed before you can go live.

    Kelly advised that ABCBS have 10 people who are available to do the testing review. So, with the number of providers to be tested (approximately 12,000), it is crucial that the testing get started right away. EDI has 30 days to review a test.

    A representative of Arkansas Hospital Association asked how many hospitals do not use a clearinghouse or vendor. Kelly replied that HAT has several of the A facilities and they are in the process of testing. The AR hospitals all use a vendor or clearinghouse. Thus, the facilities will not have to test separately. It is up to the vendors and clearinghouses to let ABCBS know which providers they represent when testing.

    SVI noted that they use NDC. Kelly stated that NDC has started testing on UB but there are still some issues.

    Kelly also noted that there is separate testing for Medicare and Regular Business; therefore, two files must be tested.

    If a provider has not filed for an extension, they will have to contact CMS directly since the form is no longer on the web. The way the Law is written now, if you are not HIPAA compliant by 10-01-03, you can be fined and your claims cannot be filed with Medicare since they must be electronic.

    Kelly stated that Medicare is hoping to have the free HIPAA compliant software available by April.

    There are no other deadlines for other transactions at this time.

The meeting adjourned at 12:20 p.m. The next meeting will be on April 16.

Note: Two items did not get announced during the PAG:

• Bobbye Garner will be retiring from ABCBS on April 4, 2003. This was her last PAG meeting.
• The Public Programs area at ABCBS is being reorganized. At this time, Charlie Clem is over the systems and financial areas. Reggie Favors is moving back into Medicare over the operational areas. Reggie and/or Charlie will attend the PAG meeting in the future.