Representatives of: Ashley County Medical Center, Arkansas Hospital Association, White County Medical Center, Medical Park Hospital, Arkansas Department of Health, Facilities Services, North Arkansas Regional Medical Center, St Bernard’s Healthcare, HealthPark Hospital, Piggot Community Hospital, Saint Vincent’s Infirmary Medical Center, Chambers Memorial Hospital

Tanya Brooks, Professional Services
Kristi Buckholz, Network Development Representative
Connie Cogshell, Network Development Representative
Rhonda Cordon, Senior Hearing Officer, Hearings and Appeals
Tracy Futrell, Provider Audit and Reimbursement
Greg Hart, Professional Services
Dr. Sidney Hayes, Medical Director, Medical Review
Barbara McDanel, Director, Medical Integrity Programs
Theresa Milligan, Director, Medicare Administrative Support
Wanda Remington, Medicare Audit & Analysis
Centhia Stevens, Provider Audit and Reimbursement
Kelly Vaughan, Analyst, EDI
Sherri Wright, Medicare Audit & Analysis

1. Welcome and Introductions - Greg Hart

Greg Hart and a representative of Arkansas Hospital Association gave opening remarks and welcomed everyone.

• Review of CMS Guidelines for PCOMAG (Provider Communication Advisory 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. 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 the types of facilities, such as Critical Access, Rehabilitation, rural, and urban, as well as outside agencies like the QIP Medicaid, Department of Health, Billing Agencies and Consultants. We are looking into being able to offer access by teleconferencing in the future to widen participation. Currently we utilize the web-site, fax, and email system to send the minutes and any notifications.
• Medicare Reform Act - 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. Another is the renewed moratorium on the Physical Therapy, Occupational Therapy, and Speech Therapy payment limitation.
• 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, http://www.hhs.gov/oig.

2. ADH Facilities Management - Arkansas Department of Health Representative

• There are now 19 Critical Access Hospitals, which includes the Little River Memorial Hospital.

3. Audit and Reimbursement - Tracy Futrell

• I am getting a lot of calls about the National Standardized Operating Amounts. CR2971 gives details concerning the National Standard Operating Amounts and their effective dates.
• A CR was issued for Critical Access Hospitals (CAH) with an effective date of January 1, 2004, dated January 16, 2004, and implementation date of April 5, 2004. It states bed limitations for CAHs have been increased from 15 to 25 total beds, which can be a mixture of acute and swing bed. The same CR says that payment will increase to 101% of reasonable costs for inpatient acute care and swing bed services for cost reports periods beginning January 1, 2004. Under outpatient the payment will be the lesser of 80% of the 101% of reasonable cost. The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 states CAHs will be allowed to operate no more than 10 psychiatric or rehab distinct part beds beginning FY 2005.
• Critical Access Hospitals choose one of two methods to be reimbursed. One is cost, which is 101% of reasonable costs and option 2 is if the physicians all agree to let the hospital do the billing then they would get 115% of the physician fee schedule. It has to be every single physician at that hospital currently or the provider would not be eligible. No one has chosen this option and we have heard that the requirement that 100% of physicians would have to agree is going away so this may be more of a factor in the future.
• The Psyche PPS Proposed Federal Register was issued in November. PPS for Psychiatric units and facilities is due to begin April 1, 2004; however, there is a possibility that this will be delayed further per the proposed rules.
• A representative asked if there was one provision in the new Medicare law, which dealt with a one-time appeal for Medicare wage index classification. Also he stated that there have been a few hospitals in Arkansas that historically have tried to get reclassified from Arkansas Rural to a MSA. Have you received any applications at this point? Tracey stated that she had not received any applications for the wage index reclassification. This may be something that they would apply to CMS for though and we would then be notified by CMS as happens with requests for geographic reclassifications.

4. Billing - Part A Data Analysis & Claims Update - Linda Lewis

• Digital Mammograms – There have been several problems with digital mammograms. If you are sending them in digitally you have to be certified to perform them and it has to be set up in our system as such. We have updated all facilities that have sent in their certifications. Providers that continue to experience problems on claims processed after January 23, 2004 should contact customer service. Also, CMS Transmittal 60, CR 2632 was just released that detail billing for mammograms. A representative asked if we should bill mammograms on separate claims. When billing for a screening mammogram, it needs to be billed on a separate claim from other services.
• Reason Code E46HJ - the FISS system is not applying the deductible amounts. A system change request has been submitted to correct this problem but we do not have an estimated date it will be fixed. Until it is corrected these claims will not go through.
• Discharge Status Codes Adjustments – All claims are processed through the CMS Common Working File (CWF). If a claim hits a CWF edit a G adjustment will be initiated. Some of these have been incorrect. A system change request has been submitted and we continue to follow up through our regular teleconferences on FISS issues. CMS is on these calls and aware of these issues. We do not have a date that this will be corrected. Theresa Milligan suggested in these cases to ask for an advance payment.
• Holding Claims – On January 1, 2004, we began holding all claims with January 2004 dates of service based on CMS guidance. This is typically done anytime there is a new system change release. These claims started to be released on January 19^th and should all be released by January 23^rd. They have released the inpatient claims, but there is a system problem with the HCPC codes which delayed the outpatient claims from being released until January 23^rd. The majority of those claims have been released but, there are a few HCPC codes that continue to be a problem.
• Paper Remits Not Balancing - Remittance Advices (RA) for paper claims submitted via the Medicare version 4010 format do not balance with the electronic RAs. This issue has been reported and is being worked, but there is no projected date that it will be corrected.
• A representative asked if it will be 30 days before they received anything. Kelly Vaughn stated if your claim was received on January 10 and it has been in hold since January 10, once it's released it will go back to the receipt date. Your 14 days is going to count from January 10. Even though it's already processed, your money is going to be sitting there for 14 days. Kelly pointed out that the clearinghouse got the notification that they were rejected so basically as soon as they make the corrections they should contact the billing personnel and instruct her to fix the errors and resend. Then that's when the claims would go through the front end of the edit system and make it to the payment system. If it rejects out on the front end, there's really not anything that we can do because it's never been received. It appears as thought you never sent it if it doesn't make it to the payment system. Greg stated that reject reports are going to the clearinghouse but the providers are not getting the rejects. The provider is thinking there claims have reached us and they haven't.
• Kelly also pointed out that when you are trying to upload a file and SSI couldn't complete their transmission, it's because they were being cut off the line. This occurs due to number of claims you are submitting. You are only allowed to send 2500 claims in one file.
• A representative stated that they have a lot of elderly patients who come to Little Rock to the allergy clinic. They give them the medication and they actually come to our hospital wanting us to give them the shot. We suggest that they to learn to give it to themselves. We have been eating the charges for administering this shot. But now we've been told to bill like an outpatient setting on a UB92. They also told us that you could bill it on a HCFA if the patient won't come to our clinic setting. Is that correct? A representative stated that you could file it if it's on a HCFA with CPT code 95115 if you administer one drug supplied by the patient. If it were two injections you would use CPT code 95117. Make sure you charge $25. A representative stated that it has not been an issue, but we have about 10 people who get regular allergy shots weekly and it adds up.
• Linda stated that she has a few copies of changes for the OCE for January of this year and the OPPS update. The handouts were distributed. Linda went over the Top 25 reasons for Medicare Provider calls, Number of Claims in Error, and by number of provider.

Top 25 reasons for Medicare Provider Calls
	#1 Claim Status
	#2 Returning Claims to Provider in a T status
	#3 Overlapping Dates
Top 25 reasons for Number of Claims in Error
	#1 Names and Medicare Number not matching
	#2 Dr name & ID missing
	#3 Modifiers
Top 25 reasons by Number of Provider
	#1 Patient Name &/or initial not matching Beneficiary record
	#2 HCPC Modifier (GN, GO, or GP) must be present
	#3 Invalid procedure code

5. Data Analysis - Sherri Wright

• Sherri gave a presentation, which was a brief overview of the Medical Review Data Analysis process. The two different processes that were discussed were Medical Review Data Analysis and the Dataline Analysis. A handout in reference to our Dataline was provided to everyone.
• CMS and the Social Security Act direct us to do post payment review to make sure there aren't any inappropriate payments for services that are not reasonable and necessary. When Medical Review Data Analysis has been performed, we take whatever action is necessary if there's a questionable pattern of practice found based on our analysis.
• The Data Analysis is performed on a collection of information from claims that's both local and national information. We can compare the utilization here to the nation or region. We look at utilization overall by all providers, by categories of facilities and types of service, and by individual providers. In addition to billing pattern identification by data analysis, we get referrals or alerts from statisticians, prepay medical review, claims area, medical directors, clearinghouse, CMS, and communications with other contractors. We conduct Data Analysis for Medicare Part A and B. We have a medical review tracking log, where we enter all of our time and what corrective action we have taken as well as the outcome of those corrective actions. We conduct a follow up every six months.
• We get information for the data analysis from HCIS, the CMS Customer Information System, and HIMR, the Health Insurance Master Record. We also obtain data from local sources: STARS (Services Tracking, Analysis and Reporting System) and FISS.
• Possible corrective actions include LCD development. The new acronym LCD (Local Coverage Determination) has replaced LMRP (Local Medical Review Policy) as of December 2003. We activate audits which allow prepayment reviews of certain types of claims. Another corrective action is education.
• In addition to the Provider Inquiry and Submission Error spreadsheets that Linda Lewis passed out, our Dataline analysis focuses on appeals. CMS sent a CR out a few months back that requires us to review appeals at all levels. We have developed several reports that show first the types. It's a combination of reasons the claims are being denied in the first place and also what is being appealed. They want us to look at those that were reversed; if the claim was denied originally and was partially or fully reversed to pay. We want to identify what the issues are.
• The next thing is the dismissals. The number of appeals that come in that we don't handle as appeals because they were not received in a timely manner. We also look at which providers request the most appeals. Greg stated that we use this data to help target what our provider education is going to be either in workshops, and what topics to cover. We try to identify the specific providers.
• A question was asked if the data was available on an individual provider basis? The appeals information is not able to single out the individual due to the fact that we only take a sample of appeal requests, then manually key them in to the system to see which provider requested the review. The automated data cannot be pulled up by provider.

6. Medical Review - Barbara McDanel

• Barbara reported that a new Prepaid Medical Review SNF audit has been put in place. It has been made more selective. Providers will receive the Additional Data Request (ADR) requesting medical information. This audit will be looking at your type of bill 211-214 and Revenue Code 0022 for all providers that fall in that category and the 486 HCPC codes. If you receive a request from the CERT contractor for documentation you need to please submit that requested documentation within the specified time frame to that CERT contractor. Failure on your part in doing this would result in a request to refund funds previously paid to you. It's also entered as an error.
• In Chapter 4, Section 4.1.3 of the Program Integrity Manual there are guidelines for the timeliness filing of requested documentation for medical review. We have found that sometimes it's delayed to the mailing system. You have sent it but we haven't received it by day 46. We are going for 15 days after that denial up to the day 60. If we get that record in we are going to automatically reopen that denied claim for you and process it based on the documentation that you sent in. We do understand that could happen. You may get a denial EOB based on non-receipt of records. If you have sent that record, just hold tight. When we get it and we reopen it, if we get it before the 60 days limit, you are going to get another letter that says we have received it and reopened the claim. We are then going to start processing the new claim based on that information. Hopefully this will cut down on added expenses for you.

• We are working within our standards. Rhonda passed out a listing of the new address and telephone numbers for the Hearings and Appeals department at the new location. The P.O. Box address will remain the same, only the physical address has changed. Theresa Milligan stated that we would be posting this information on the web-site.

• We currently have 67 submitters in production for Medicare Part A. We have 28 that are testing. The providers who are currently testing are having a lot of problems. We are working through these issues. Please keep in mind that if for some reason you see a drop in your payment, or if you see an increased amount of denials. Please contact us as soon as possible.
• A representative stated just how great Kelly and her group have been in assisting them with any issues they have had. Medicare has gone as far as driving to meet a provider with their check.
• A representative asked if Medicaid was doing any better. He stated that they are getting better but they still had a few issues to resolve. He was asked if he had spoken with Medicaid personnel and stated they thought that generally things had improved across the board.
• A representative stated that her biggest problem with Medicaid was the provider reps not being available. A representative stated that Medicaid personnel had informed him that the provider reps have been tied up due to all the problems they are having. The memo he received this morning stated that they were getting back on track with everything.
• For everyone who has not attempted to become compliant we suggest that you begin your testing process. We are no longer setting providers up to send the National Standard Format. Anyone wanting to do electronic billing must transmit in the HIPAA compliant format. For anyone who is currently sending the National Standard Format we are still accepting those but those providers need to be doing testing to be compliant. We will be monitoring those people who are not doing anything as far as not doing anything as far as becoming HIPAA compliant. We are going to be monitoring the volume of claims they send in. As an overall Arkansas is looking real good.
• A question was asked on the 67 that are currently up and running, if you have two facilities that are ran through the same pathway, will they be included in the total count or are they considered one? They are considered one.

9. Provider Education - Greg Hart

• CMS has a web-site for the Medicare Reform and we sent out a notice to all the members regarding their, "Issues of Day" link. You can go to http://www.cms.hhs.gov/medicarereform to go directly to the page.
• We are currently building specialty listservs that will allow you to sign up just for hospitals and critical access hospitals. We are projecting to have this completed in the next few months. We are also looking at changing out home page so there will be a Part A area to make it easier to find pertinent information faster.
• A question was asked, under the interactive fee schedule is that only for Part B at this time? Yes it is for Part B only. Part A is a little difficult to do as an interactive fee schedule because of the number of variable. Some of the information is available through the Remote system.
• A question was asked concerning APC outpatient rates and the final rates are they out? CMS has a link to the final rule, http://www.cms.gov/providers/hospital.asp.
• All the CMS manuals are on the web-site, http://www.cms.gov/manuals, and they are available for access.
• Workshops are currently being scheduled for this year. We are looking at the July and August time frame for those workshops.
• A representative for the Arkansas Hospital Association stated that AHA endorses the National Quality Initiative program. CMS and the business community also endorse it. Every hospital this fiscal year got a 4 market basket update in terms of the PPA rate. In 2005 and 2006 every hospital under the Medicare law will get a full market basket update, if the hospital is participating and submitting data to the NQI. Any hospital not submitting data to NQI will get full market basket minus 0.4%. It doesn't sound much but after running the numbers on a 75-bed hospital, it could mean as much as $25,000 to $35,000 in total Medicare reimbursement per year. I encourage hospitals to participate because this is something that will not be going away.

The meeting was adjourned at 12:35 p.m.

The next meeting will be held at the Medicare Services Building located at 515 W Pershing Blvd, North Little Rock, Arkansas.

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• Explore the option of providing teleconferences for future PCOMAG meetings.
• Put together a summary of all current billing issues and send to Paul Cunningham to publish in the upcoming Notebook publication.
• Arkansas Hospital Association will share a distribution list of all CEOs and CFOs once they have received approval. This distribution list will be used to send urgent information as it develops.
• Send a notice that will announce when the Discharge Status Code Adjustments have been corrected by CWF.
• Place a popup box on the web-site concerning current billing issues. Look into developing a link for Billing Issues only.
• Send a notice that will announce when the HCPC codes have been corrected and the outpatient claims have been released.
• Post the new physical address and telephone numbers for Hearings and Appeals on the www.arkmedicare.com web-site.
• Develop a listserv just for Hospitals and Critical Access Hospitals. Also develop a link strictly for Part A.
• Finalize the 2004 workshop schedule