Representative from: Practice Plus/Baptist-Health, AR Chiropractic Society, AR Medical Society, AR Ambulance Association, Chiropractic Association, AR Osteopathic Medical Association, Medical Practice Consultant, Inc, and AR Medical Society

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
Jim Cook, Wanda Remington, Medical Review Audit and Analysis
Rhonda Cordon, Sr. Hearing Officer, Hearings and Appeals
Gary Eads, Manager Part A and Part B Claims
Merle Francis, Manager Professional Services and Provider Enrollment
Greg Hart, Professional Services
Wanda King, Manager, Medicare Secondary Payor
Susan Moore, Senior RN, Medical Review
Wanda Remington, Medical Review Audit and Analysis
Sharon Robinson, Supervisor, Medicare Claims
Priscilla Secrest, Supervisor, Medical Review
Kelly Vaughan, Medicare EDI Analyst
The meeting was called to order at 10:05 a.m.

• Greg welcomed everyone and introductions were made around the table.

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. Greg asked if there were any groups who should be represented that are not currently represented. If you know of a group that should be listed please send call information to Greg Hart at gphart@arkbluecross.com. A represented suggested that WebMD be added to the list of participants.
  • Greg also inquired about how to get the word out to providers concerning updates, meetings, etc. Greg stated that once they receive information from our meetings to please distribute the information, put it on your web-sites and in your newsletters. Currently we utilize the web-site, fax, and email system to send the minutes and any notifications. When we are sending information out to you concerning updates or changes we are attaching a survey for you to complete. This survey is asking you to rate the information you received. We want to know if it was helpful and if you passed it on to others. Some organizations have placed items on their website or in their newsletters.

• A handout from the CMS Medicare Modernization Act page (www.cms.gov/medicarereform) was given concerning Physician Scarcity. One of the changes coming up is a 5% incentive for providers in certain areas. We have started receiving CMS Change Requests concerning this matter. The implementation date has set for October 4, 2004. They are also revising the Health Profession Shortage Area (HPSA) program. Part of that initiative is to discontinue the requirement to use the QU and QB modifiers. This will also be implements as of October 1, 2004.

• CMS is moving toward national COB agreements with supplemental insurance contractors instead of individual contractor agreements. Originally it was to go in effect in July but they have decided to do a pilot program with 8 sites. Instead of starting July 2004 implementation was moved to October 1, 2004.

• Starting in July 2004 there will be one common telephone number for Beneficiaries to call in to customer service. The number will be 1-800-MEDICARE. This will be published for the beneficiaries and is not for calls by providers.

• Currently Provider Enrollment does have a backlog. CMS implemented a new enrollment system in November 2003 which requires a significant amount of time to enter an application opposed to past methods that were used. The new PECOS system requires a 4 to 5 days step process whereas with the old system we could process an application and complete it in one day. Additional staff has been hired as well as temporary staff has been added to support the increased workload. We are using and have been using overtime as well as working on Saturdays to decrease the backlog. Our goal is to be back up to normal production by the middle or end of July 2004.

• With the new PECOS enrollment system, one of the things that slows us down is when you submit a change to your existing provider information and we must then go back and request that they complete an 855 enrollment form. Many of the providers in Arkansas have been established for years prior to the use of the 855 enrollment form. If the information was not entered into the system by CMS when the systems were transferred then we are required to go back and get a complete 855 enrollment form completed.

• ? A representative asked if it will always take 4 to 5 days to process the applications. Merle stated that due to the new system there are certain steps we have to take. The system will only allow us to enter information in the provider enrollment system first. Once that has been entered and the approval has been sent we then can enter the claims information in our claim system. We will have to wait for an approval before we can enter additional information.

• ? A representative asked if it was best to just complete an 855 if you just have a change. You will only need to complete an entire 855 if you have never completed one in the past. The 855 enrollment form can be found on the web-site at www.arkmedicare.com under Provider Enrollment. If you are having problems getting your provider number and it is causing a financial hardship, please call immediately.

• ? A representative asked how this will impact a physician that needs to move to another facility. You must complete an 855R that gives and effective date. Please give as much notice as possible. This information is going into a national system.

• The Provider Enrollment customer service lines hours are from 9:00 a.m. – 3:00 p.m. and the toll free number is 1-866-582-3251. You may call this number for all inquiries and status updates concerning your application.

• Currently there is not a backlog of claims to process. We are now at 7 days with electronic claims and 12 days with paper claims. Remember that there is a 14 day hold before they can be paid.

• Address of Facility providing service - Item 32 of the CMS Form 1500. In the November 2003 newsletter pages 17-18 we published CR2631 that states "Any time service is rendered other than the patient’s home then Item 32 needs to be completed. This was effective on April 1, 2004. Many paper claims began being denied starting April 1 for this reason. Please note that all ambulance claims are included in this requirement to complete Item 32.

• In the October 2003 newsletter, page 50, we discussed the requirement for the date last seen for Physical Therapy and Occupation Therapy be completed in Box 19 on paper claims and on the HA0 for electronic claims. They are also asking that they indicate the referring providers UPIN number. This date should reflect when the patient saw their primary care physician and was referred to Physical Therapy or Occupational Therapy.

• Because of HIPAA, everyone must use the same ANSI reason codes. The standardized set of reason codes caused us to expand the codes available for use as well. Though more codes are available, the added ones were ones that Medicare does not use. On Crossover claims it was noted that MA18 indicates that the claim has crossed over. The definition for this code was revised. On our web-site www.arkmedicare.com, provider page, under the resources area is the ANSI Reason code booklet.

5. MSP – Wanda King

• A handout was distributed to everyone that consisted of four fact sheets giving a general overview of the Medicare Secondary Payor (MSP), which is now in the MedLearn section of the CMS web-site, www.cms.gov/medlearn/pubs.asp. These handouts have a lot of helpful information that may be beneficial to your billing staff.

• Whenever you send a refund to MSP please make sure you have the patient’s HIC number, name, and any other insurance information attached so we will know who this applies to and we can apply the money correctly.

• On claims please provide a full primary EOB and all pages of the EOB. It is okay to draw a line through names that you are not referencing but we must have all pages of the EOB. If there are any denials from the other insurance company we will need that attached as well. We also do not allow any handwritten break down of charges. Please make sure this is on the EOB.

• Wanda stated that she is seeing about 70% of MSP claims coming in electronically and that is an increase which is very good to see.

• A representative stated that he has problems with a patient not stating if they have a secondary insurance. It was stated that the providers are to make sure they are asking the patients and to also make sure they have documentation that will support the fact that the patient was given every opportunity to supply this information to them.

• ? A question was asked if when the 270 is used to check eligibility will it come back and state if this is the primary insurance or secondary insurance. Currently it does not come back stating if this is the primary or secondary.

• Pat distributed a handout on Telephone Review Criteria. This is to keep the provider from having to send in paper reviews. We can now take them on the telephone. The reviews are only done minor issues. We cannot do a review on anything that will take a medical determination. If it’s anything that is medically necessary or additional documentation it will have to be dropped to paper.

• A scenario was given concerning pain management. If a provider has pain management as a specialty but anesthesiology is their second specialty, if they are doing CVL placement and anesthesia for the surgery at the same time, the anesthesia is denying. This is happening because pain management is showing up as primary. This cannot be done by telephone review. It has to be submitted to paper.

• ? A representative asked what is the hold time when you call in for the telephone reviews and how many can we do on one call? You should not have more than a 90 second hold time. You can do 5 reviews per call. You can hang up and call right back and do 5 more.

• Some of the errors were HIC changes, provider number changes, and correction of dates of service, correcting procedure codes, and correcting or adding modifiers are things that can be done on the telephone review. If it denied unprocessable we cannot do this on the phone. You must submit a new claim.

7. Medical Review – Priscilla Secrest/Susan Moore

• There are 16 providers in Arkansas on the provider specific Critical Care audit and we are not receiving any documentation nor are we receiving any claims. It appears that some providers have quit using the critical care CPT codes to avoid the audit. This is an educational process to help provider so we encourage all providers to use the appropriate code for the service rendered. Providers remain on the audit until their denial rate declines.

• Greg passed out a new pocket size Critical Care guide. This guide will assist those providers who are billing for Critical Care.

• Chiropractor’s provider education is going very well. We now have 5 providers who have been taken off of their provider specific audit. We are receiving good feedback. The Chiropractic web-based training course has received rave reviews.

• Jim gave a presentation about the CERT program (attached). AdvanceMed is the National CMS independent contractor that evaluates all contractors to see how well we process claims and if the claims are paid correctly. If providers receive a request for records from AdvanceMed they need to comply. Starting shortly there will be more extensive efforts to contact providers that have not returned medical records as well as those with claims processing errors.

• The group discussed the CERT process and several members expressed concern about the lack of clarity in the requests that were sent to providers from AdvanceMed as well as their handling of the records returned. Providers need to call the number on the request if they need clarification about who AdvanceMed is, what they are asking for, or any other part of the process. The feedback we, as the contractor, have received has been channeled back to CMS and AdvanceMEd during periodic teleconferences.

• We have received some appeals on CERT claims. If a provider disagrees with the decision by AdvanceMed, the provider would go through the normal Hearing and Appeal process with ABCBS. The majority we are receiving is where the records were not received.
• We are currently on hold for the CMS QUICK project to revamp the Hearings and Appeals process. CMS has stated that this is going to happen and therefore, your hearing level will be eliminated at some time. We currently do not have any dates when this will start.

• Recently EDI Services sent a letter (attached) out to all electronic submitters that we have identified as not compliant. The letter also reference CR2981 which will become effective July 1, 2004. This CR states that if you send in a paper claim your payment floor is 27 days. If you send in an electronic claim that is any format other than the 4010A1 format, it will be considered a paper claims and the payment floor will go from 14 days to 27 days.

• There are several providers who did not submit a contingency plan when the deadline for compliancy was extended. These providers are not submitting HIPAA compliant claims and they are not testing HIPAA compliant claims. Those providers must remember that once the contingency plan ends, for those providers the cash flow will end as well.

• ? A representative asked what information we could provide concerning WebMD or any clearinghouse for that matter.

• We have had meetings with WebMD and will continue to have meeting with them as we resolve various issues. We have dedicated personnel at WebMD that are assisting us with various issues.

• Greg submitted a diagram which outlined Arkansas Part B progress of providers submitting HIPAA compliant claims. We are right at 78% which is the national average.

• On the EDI section of the Arkansas Medicare web-site (www.arkmedicare.com) there are downloadable, such as, the Companion Guide which give information on what fields are required.

• We are continuing to hold our workshops as one of the tools for educating the provider community. The schedule of all workshops can be found on www.arkmedicare.com

• MedLearn Matters is a new format from CMS and is a very good tool for provider education. MedLearn publishes information in an easy to read format.

• A new web-based training course will be implemented on Wound Care. We will also be conducting a Wound Care workshop. We will be publishing letters to go out soon concerning this workshop.

• This Friday, May 21^st, the CMS Open Door Forum for Physicians will be held. Information is on www.cms.hhs.gov/opendoor.

• Greg also asked what information we need to communicate to providers that we currently are not doing or need to do more of in the future.

• The MedGuide has recently been revisied and can be found at www.arkmedicare.com.

• The next meeting will be August 18, 2004 in the Medicare Services building in North Little Rock, AR.