Representatives from: AR Foundation for Medical Care, Ashley County Medical Center, Arkansas Hospital Association, UAMS, Arkansas Department of Health, Arkansas Department of Health, Piggott Community Hospital, North Arkansas Regional Medical Center, St Bernard’s Healthcare, HealthPark Hospital, Piggot Community Hospital, Saint Vincent’s Infirmary Medical Center, Chambers Memorial Hospital

David Bailey, Supervisor, ABCBS EDI
Tanya Brooks, Provider Education Specialist
Kristi Buckholz, Provider Education & Training Representative
Pat Clements, Provider Education & Training Representative
Connie Cogshell, Provider Education & Training Representative
Jim Cook, Medical Review Audit and Analysis
Rhonda Cordon, Senior Hearing Officer, Hearings and Appeals
Amanda Crosby, Medicare Provider Audit & Reimbursement
Greg Hart, Professional Services
Linda Lewis, Supervisor, Medicare Part A Claims and Customer Service
Sherry Price, Medicare Secondary Payor
Deborah Reichard, Medicare Medical Review
Sherri Wright, Medicare Audit & Analysis
Kelly Vaughan, Medicare Systems Analysis

1. Welcome and Introductions

• A representative of the Arkansas Hospital Association gave opening remarks and welcomed everyone. A brief summary which outlined the purpose of this group was given. 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 a representative of providers who bill under Part A, 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.

2. Updates – Greg Hart

• PCOMAG Minutes: Greg explained that we would like to publish everyone’s name in the minutes, but we must get member’s consent to do so.

• Handout #1: Facts Sheet for Sole Community Hospital, Rural Health Clinics, and Critical Access Hospitals – These sheets can be found at www.cms.hhs.gov/medlearn/pubs.asp, they offer a good summary of these specific areas.
   
• The 75% Rule for Inpatient Rehabilitation Therapy went into effect July 1, 2004. Last week the Appropriations Committee amended the current bill. The bill has not been signed. Until CMS guidelines change we will continue to go by the 75% rule. Paul indicated that if this bill goes through as it is written; it will eventually cause a great increase which will result in everything going back to where 75% of our admissions to an inpatient rehabilitation facility have to come from a set of certain DRGs. This is important for future hospitals because it will reduce access to services for some beneficiaries. For acute care hospitals, it means that you don’t have a place to transfer those patients who are ready for inpatient rehabilitation care. Arkansas Hospital Association (AHA) is working on this. The House Appropriation Committee in its mark up of a budget bill, placed language in the bill that will require CMS to get with the institute of medicine and have them conduct a study. Greg announced that the Arkansas Hospital Association Notebook published this information on the front page of their July 20, 2004 issue.
   
• Handout #2: Office of Civil Rights Letter dtd. May 17, 2004: This was a notice to clarify HIPAA privacy guidelines on certain issues. It answers questions on what HIPAA will allow a provider to share with other healthcare facilities, insurance companies, and family members. Issues were brought up at the Skilled Nursing Facility (SNF) Communication Provider Advisory Group about the difficulty of finding out about SNF patients that are brought to the hospital for emergency care.
   
• Handout #3: Supplemental Hospital Compliance Program Guidance: In the June 8, 2004 Federal Register a supplemental guideline for Hospital Compliance Programs was published. These draft guidelines were published in the Federal Register on June 8, 2004. A copy can be obtained through the OIG website, www.oig.hhs.gov/authorities/docs/04/060804hospitaldraftsuppCPGFR.pdf.

3. Data Analysis

• A member of the Medicare Part A Data Analysis team presented the most recent quarter’s data analysis results to the group, seeking recommendations on additional education interventions. The 3^rd Quarter Dataline Report (attached) was distributed. The purpose of this report is to provide you with information on what kind of inquires are being asked by Part A providers and what kind of claims submission errors are being made on Part A claims. They also show what the appeals issues are with the claims.

#1 - Claim Status
#2 - Provider Request Claim Adjustment be Returned
#3 - Overlapping Dates

Top Error Reasons for All Med A Providers – by Number of Claims

#1 – Patient name and or initial not matching Bene Record
#2 – Incorrect Admission Source or Type
#3 – No Appropriate Modifier

Top Error Reasons for Appeals Reviews – for All Med A Providers

#1 – Lab denial per diagnosis
#2 – Condition did not warrant Type/Freq
#3 – Radiology Denial per Diagnosis

• We have discovered that the lab denial per diagnosis is the number one reason for errors on Appeals Reviews and this is because of the Everyone in the group was encouraged to submit examples where claims were submitted according to the latest NCDS and that claim had a covered diagnosis, yet it was denied forcing you to appeal. One member stated she is working on compiling examples and would send them to Greg. The members were asked if they could place the Bene claim number and possibly the correspondence claim number on each correspondence. Greg asked that all information be sent to him first and he will then route it to the correct department.

• A representative stated that they need to make sure they match the diagnosis with the test if they have multiple problems when they bill. For an example, she had one that had 4 lab tests and 3 diagnoses to go with them, make sure the diagnosis line up with the lab test. She stated that measures have been put in place and they are catching these on the front end.

• A representative has had instances where the primary diagnosis wasn’t a medically necessary diagnosis but there was a secondary diagnosis and it would deny but often medical review paid it. She is having a hard time figuring out how they can match up every ABN with each test in order to place the right modifier with the CPT code. Another representative suggested that when they receive their hard copies of their bills they attach their ABN to the bill.

• It was explained how the reviews are looked at. A representative stated that he recently took 6 cases to the Administrative Law Judge (ALJ) and 5 of those were returned in his favor. How many cases are denied by the Intermediary that go to the ALJ and are then overturned? A representative from Hearings and Appeals answered by stating that the majority of cases that go to the ALJ are overturned and do pay at least partial if not full. This is due to the fact that the ALJ does not go by the Intermediary or Carrier Local Medical Review Policies. They go solely by the law and their interpretation of reasonable and necessary.

• This information concerning top denials will be incorporated into our workshop material for the upcoming workshops. The providers who have been identified as the top receiver of denials will be contacted by our Provider Education staff. In addition, the group discussed what other means was available to obtain the information that providers were requesting by calling and writing. This will also be covered during the workshops.

• A representative wanted to know if CMS has placed on their web-site a list of zip codes that pertain to labs for hospitals with 50 beds or less where you could get a better reimbursement. Greg stated that there is a CMS data site that has some zip code listings but wasn’t sure if this was the one she needed. The representative also stated that it should have been released around April 2004 but so far she hasn’t been able to locate it.

4. ADH Facilities Management

• We now have 21 Critical Access Hospitals (CAH). If all goes through with the PPS it will allow them to have the psyche units then this will increase the number of Critical Access Hospitals. A representative of Arkansas Hospital Association stated that we have 84 general acute care hospitals and that would put us right at 25%. It was also announced that a long time member of the PCOMAG has retired. Members of the PCOMAG asked that their appreciation for her support as a former member be passed.

• A member of our Medicare Audit and Reimbursement staff presented several issues to the group, seeking recommendations on additional education interventions that would be beneficial to the provider community. In the past Provider Enrollment was not involved in the certification process of CAHs. They now request that a part of the 855 be completed. The forms are located on the CMS web-site (www.cms.hhs.gov). A representative asked if it has been established that when a hospital starts new services like clinics and so forth that only part of the 855 is required to be completed. Amanda stated that it depends, if it’s a new department at the hospital, an 855 may not be necessary. You will probably need to do a provider based attestation. This will help us determine if you are provider based. If you are applying for a new provider number for something such as a home health agency, exempt type unit, or anything like that you will need to complete a full 855

• TOPS Payments: We had ceased the TOPS payments as of January 1, 2004. It was then reinstated at the end of January. The timing was such that the pricer program did not calculate the TOPS payment for everyone that might have qualified. It did for some, but not for everyone. We received instructions from CMS to calculate retroactive adjustments for those providers who should have received them but didn’t. The instructions stated that they must be done by the end of July 2004 and they have been completed as of today. Some of you should have received them or will receive them. If you were supposed to receive them and hadn’t received anything contact Centhia Stephens in Audit Reimbursement. A representative stated they were one of the hospitals they overpayed. They received a letter stating they were overpaid and the money must be returned in 14 days.

• In the past we requested attestation statements from PPS exempt hospitals and units stating that they are to continue to qualify for the exemption. We will be re-implementing that in the near future.

• CMS has given new instructions as to what is required in order for us to be considered current in cost report settlement process. We will be working next year to meet a new deadline of September 30, 2005 to be current within their new standards. We will count heavily on your participation. It’s a 2 year process that must be completed in 1 year. A representative asked if there was a particular criteria for this process. It was stated that a cost report must be settled within 12 months of our acceptance if we don’t audit. If we do audit, there are other time frames that are applied. We will settle cost reports a lot faster than we have in the past.

• There is also a push from CMS for appeals cases to be processed more quickly. The case backlog at the PRB is tremendous. They are making an effort to cut that by 50%. This will not only place pressure on us but also you the provider. There are two people in the office dedicated to working those appeals and they are Amy Richmond and Rob Bledsoe.

• A representative stated that as of October 1, 2004 Ashley County Medical Center will be a Critical Access Hospital. How will they base their payment and on what cost report? Will it be the most recent one? It was stated that we generally try to work off the most recent filed copy. If there are any new expenses that we know of starting October 1, will those be considered? It was stated that she will need to get with them as the time approaches.

6. Claims

• A member of our Medicare Part A claims staff presented several issues to the group, seeking recommendations on additional education interventions. Claims have been held up in OPPS and that was the result of the July release. (Edit or location?) 709TA claims were kicking out for ambulance when there wasn’t actually ambulance on the claim. They have all been worked, but if you have anything that’s still out there, please call our Customer Service Representatives (CSRs) and they will let us know to get those claims released. The group felt no additional education was required on this item.

• We are getting a lot of calls that claims are kicking out with units. We had to put more edits in place due to an issue where a lot of units were entered which caused a very large amount to be paid in error. Now, if you have several units in any code, it will kick out and be returned to you for verification and corrections as necessary. The group felt no additional education was required on this item.

• Beginning July 28, 2004 all beneficiaries will need to call 1-800-MEDICARE. The old number will go away. Please communicate this number to all beneficiaries.

• There is also a problem on the system with some medical policy parameters. It has to do with multiple HCPC codes. This issue is being addressed. The group felt no education was necessary at this time. A representative also passed out a list that had the latest transmittal listings. It also list the implementation dates. It was asked if any of the representatives got a chance to go to into the web-site often and read the transmittals. A representative indicated that he does visit occasionally but sometimes the information is so overwhelming that it will take a mass amount of time to review this information. Greg stated that MedLearn Matters is a summary of the CMS Change Requests (CRs) that give providers an overview of the information pertinent to them with links to the full document. This should help providers review changes and concentrate on the ones that affect them. Additionally, our email updates provide a summary link of the changes placed on the website.

• Everyone was reminded that the Provider News is a great source of information as well. A representative stated that the pop-up box on the web-site was helpful but should be changed more often.

• On credit balance reports we are stressing that you please get them in on time. We are now holding up any checks in which we do not receive a credit balance report for. If you don’t have any credit balances we still need you to send the forms in stating you have zero balances. You have 30 days from the last day of the quarter. Amanda stated that it must be the original with the original signature. A representative suggested that this be placed on the pop up notice that appears on the web-site and the group concurred with this recommendation.

• A representative from the EDI/HIPAA department stated that she has been receiving a lot of research calls on providers not getting paid and it has to do with the payment floor. It was stated that if your claims have something on them that are not HIPAA compliant then your payment floor will go to 27 days A representative from the EDI/HIPAA asked everyone to make sure the clearinghouse they are using are submitting their claims in the HIPAA compliant format.

• A representative of the Medicare MSP staff presented several issues of concern to the advisory group, for recommendations on education. When you send your credit balance report, you can send them together but make the MSP portion separate. If you are sending the value codes 12, 13, and 43 which are your group codes, then along with that credit balance report we need an explanation of benefits to help us determine the write offs.

• On claims where we are holding your payments there are few things you need to do. Where the group insurance is applied to the deductible, the occurrence codes 01 – 06 and 24 with a corresponding date, you are not going to use and MSP value code for the value code 44. You are going to put Medicare in the primary payor position and the other insurance in the secondary payor position. You are then going to add in the remarks field that the primary insurance applies to the deductible. This should all be on your claims.

• The other issue is if the other insurance has denied the claim you are going to send occurrence code 01-06 and 24 with a corresponding date. You are not going to show value code 44. You are going to enter the MSP code with a zero paid amount. You are going to place the primary insurance in the primary payor position with payor code C and you are going to add in the remarks field as to why the other insurance denied the service. The claims are kicking out and causing a lot of problems and we need your help.

• A representative stated that she is doing at least 20 to 30 refunds a week because Medicare is crossing over to multiple insurance companies, Medi Pak, Wassau, and Medicaid Firestone. All of them are Medicare Beneficiaries but they have multiple co-insurances and Medicare is not aware of them. It was stated that if Medicare is primary this would go to the claims department. It was also requested that examples be given to the claims supervisor. Greg asked that all examples be forwarded to him and he would distribute them to the right department.

8. Medical Review – Deborah Reichard

• A representative stated that he had a meeting last week with most of the free-standing inpatient rehabilitation facilities talking about this proposed LMRP for the inpatient rehab care. It has generated a lot of concerns. A lot of hospitals say that it is more restrictive than the 75% rule, and that’s probably not the case. There is a concern that what is being proposed does not accurately reflect medical practices in the state of Arkansas. He heard that we are accepting public comments from all the states in the consortium and that whatever LMRP is adopted will be adopted for all states. This really raises a flag because there will be concerns about the common medical practices here and the common medical practices in Rhode Island, and the differences between the two. A representative would like to make a verbal request today with a written follow-up, about the possibility that this draft of the LMRP could be withdrawn or suspended until after CMS gets with the technical committee and completes a formal study of the 75% rule. It was stated that this would have to be looked at by the Medical Director, Dr. Sidney Hayes. The representative also advised that the best way to get your comments or concerns on any and all policies is to submit them through the website.

9. Comprehensive Error Rate Testing (CERT)

10. Hearings and Appeals

• Information from a member of our Hearings and Appeal staff was presented for consideration and educational recommendations. Concerning the CERT program, the CERT appeals we’ve received in Hearings so far have been because they did not receive information that was requested. Our volumes are picking up on the CERTs. They will deny the claim and you will get an overpayment request and then you will have to go to Hearings if it’s over $100.

• CMS is starting a process, which is the QUIK process. It will eliminate the Hearing Officer, there will be 4 contractors across the country that will look at the claims after the review is done and within a 30 day time period they will determine if they have justification to send it back to the carrier to have payment issued, if not it will go to the ALJ. The ALJ will have a time frame to get the responses out. Currently they do not have a time frame.

• A member asked if you have a LMRP that says "X" and it’s appealed and the ALJ says that "Y" is correct, do you change the LMRP or do you keep letting people appeal that over an over? Rhonda explained that LMRPs are local policies to clarify CMS guidelines and are established at the local level. It was stated that the ALJ does not look at medical policies; they strictly go by the law and whether the service was reasonable and necessary. The hearing officers follow CMS guidelines as well as the LMRPs. Paul asked if the same judge hears all the appeals and the response was no, there are different judges. Once the QUIK is implemented, there will be ALJs throughout the country. If you have appeals pending with the ALJ that you haven’t received a response on you should follow-up. The ALJs are transitioning from governance by the Social Security Administration to the Department of Human Services. Part of this transition to the QUIK requires that existing case loads should be completed prior to the move to the Department of Human Services in October 2005.

• A question was raised if, in our development of consortium policies, Arkansas providers were following the standard of practice in other areas, such as Rhode Island. Greg stated that in developing those policies we look at utilization data and we also do a lot of research on other contractor’s policies and National Association guidelines. At the bottom of the policies are a lot of resources that identify what was used to develop the policy. Each state has their own Carrier Advisory Committee with local physicians or local specialists that do review them and consider the standard of practice in their state. After the policy is posted for comments there are instructions on our web-site for reconsiderations. Paul stated that one of his concerns was that in talking about the inpatient rehab policy, he was told that they had not heard from any physicians at the time. Greg stated that when a policy is developed there are three specialties on the advisory committee, and Dr. Hayes works with them specifically in the hopes that they talk with their peers. We do try to get a lot of review on the policy before it’s finalized. The normal policy comment period is 60 days.

11. EDI/HIPAA

• A member of our EDI department presented an overview of the most recent EDI activities so that the group could recommend the necessary educational interventions to keep the providers current. Handout #3: There were some Med Part A edits that went into the FISS system the first part of July. Prior to the new edits going in, historically your files did not go through any type of editing process. Now they are going through an editing process. Claims are rejecting. In CR 3031 it states why the edits are to be implemented. It has to do with the COB information that Medicare needs to crossover these claims. The information was not being placed on the 4010 transactions, so some rules and regulations were developed to make sure it’s there.

• On the last page of the handout is a list of Most Common Med A Rejects for Arkansas. Please share this information with your office staff. The first one on the list had 255 occurrences stating All Claims Have Errored for This State; this is a complete file reject. A taxonomy code is not required to process or pay a claim but if you choose to use one it has to be correct one. The other major one is the Admit Hour is Invalid or Missing Time. Some provider’s systems were not sending valid time. When you receive a reject that means that it has not reached the FISS system. You will no longer be able to go to FISS and correct the claims. There is a new report on the system and the extension is FIS and it has your accepted and rejected claim information. It’s very important that hospitals begin downloading this report and confirm that what you transmitted the previous day was accepted and identify what, if any claims were rejected. We once were at 1% error rate and now we are running at 35% percent.

• MedLearn Matters is a helpful web-site. It is very important that you get out there and read the information. MedLearn Matters give you a great summary of the CRs.

• We have 99% of all the Medicare Part A claims that we receive are now in the HIPAA compliant format. About 86% of the submitter populations have converted over to the ANSI format.

• It was stated that the edits are not listed on the web-site. We are working on trying to obtain these. The only information we have to this date is the MedLearn Matters. There are over 1100 new edits on the FISS system.

• The AHIN system has the 997 and Batch Processing Report Rejects but it does not have the Medicare acceptance and reject report for FISS and MCS. At the recommendation of the Rhode Island Provider Advisory Groups, EDI is preparing guidelines for interpreting the various electronic submission reports. Members felt that this would be a useful tool.

12. Arkansas Foundation for Medical Care

• The reporting hospital quality data of Annual Payment Update Notice of Participation form that was required as of August 1, 2004, all the eligible hospitals have sent theirs in. They also requested that all acute facilities that were not going to have any AMI ammonia or heart failure cases to send in the zero cases form, and to our knowledge all of the hospitals had done this as well. This is mainly for specialty hospitals that treat those kinds of patients. It is important that if anyone finds themselves not having any cases in all three categories then they should send in that form for every quarter that it occurs in.

• A report was sent to every hospital that identifies how many Medicare cases CMS predicts you should be sending in for each topic. The requirement form that is requested only if you had less cases then the number they recommend your hospital needs, will need to send a letter, preferably with the signature of the person who signed the APU Notice of Participation form. The deadline for the forms is August 1, 2004. A while back we reported that every hospital had someone registered for Key Net exchange, which is the clinical data warehouse where all the data has to go through. We now have an issue with turnovers. You should always register more than one person. Providers should watch their email for notification.

• Greg stated that the Arkansas Foundation for Medical Care will be participating in the upcoming Hospital Workshop and the Skilled Nursing Facility Workshop.

13. Provider Education

• On August 19, 2004 we will have the Critical Access Hospital Workshop and on August 17, 2004 we are having the Skilled Nursing Facility Workshop. We are working through Sandy Hayes at the Arkansas Department of Health for the Critical Access Hospital Workshop, which will be held at the UALR Cooperative Extension Service building in Little Rock. The Skilled Nursing Facility workshop will be held at the Wyndham Riverfront in North Little Rock.

• In reference to the web-base courses we are beginning to develop courses for Part A. If you have any ideas or suggestions for subjects you would like to see a course on please let us know.

• Paul wanted to know if Medicare will be going toward using bar codes on documents for tracking as is used by ABCBS Private Programs. Greg stated that he wasn’t aware of this but he would check into this. Members felt that this would be worthwhile pursuing. Greg will take back to Medicare Operations.

• Members were asked if there were any other items that needed to be clarified and communicated to hospitals. If so, please forward them to us.

• The next meeting will be October 20, 2004