Provider Advisory Groups

Attendees:
Brent Beaulieu, Manager, Baird, Kurtz, and Dodson, LLP, Arkansas HFMA
Greg Crain, Vice President Patient Services, BHRI
Paul Cunningham, Senior Vice President, Arkansas Hospital Association
Bob Hughes, Hughes, Welch & Milligan, LTD.
Amanda Goodwin, CMS Dallas Regional Office
Jason Springs, CEO, HealthPark Hospital
Tom Stickel, Clinical Service Coordinator, Piggott Community Hospital
Joe Wewers, CHFP, Mid South Credit Bureau, Arkansas HFMA

ABCBS Staff:
Pat Clements, Provider Education & Training Representative
Rhonda Cordon, Senior Hearing Officer, Hearings and Appeals
Amanda Crosby, Medicare Provider Audit & Reimbursement
Gary Eads, Manager, Medicare Claims
Greg Hart, Professional Services
Dr. Sidney Hayes, Medical Director
Wanda King, Manager, MSP
Susan Moore, Supervisor, Medical Review
Sara Phillips, Medicare Part A Claims and Customer Service
Sherry Price, Medicare Secondary Payor
Deborah Reichard, Medicare Medical Review
Wynne Dee Throop, Medical Review
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. CMS Comments - Amanda Goodwin

• Amanda reemphasized the policy of the group. She stated that the group is a place to receive information to take back to the provider community. Amanda also encouraged the members to call in to the open forums conducted by CMS. You can access the schedule for the open forums by visiting www.cms.hhs.gov/openforums. You can also voice your concerns during these calls.

4. Provider Education – Greg Hart

• Greg gave an overall summary of the Hospital Workshop held on August 4, 2004 and the Critical Access Hospital Workshop 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.
• 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 will 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.
• 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.
  
  ACTION ITEM: Greg will look into the timeline of getting this activated on the website. He will also look at the how instrumental this will be among all providers.
   
• 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. We have also received a request to conduct a workshop on hospital based ambulance and will be working to schedule this as well.

5. Data Analysis – Greg Hart

• We have been using this information in our workshops as well as addressing specific topics in our newsletters. Many of these top problems could be solved by using the Remote DDE system. We have addressed this as well but haven’t seen much change. Greg asked if the group felt that this type of information was useful.

• A representative stated that it is helpful but they would like to see it facility specific. This will allow them to address the departments within their organizations.
• A representative suggested that when they began to look within their organization they should look at who is in charge of patient access, the admission staff. A lot of errors occur during the admission process. The group agreed that this was a good suggestion. A recommendation was to look at this as a possible topic for a future workshop.
• Greg presented a draft of a summary sheet of the top claims submission errors with a description and solutions. The group agreed that this information would be helpful and that placing it on the website and in the newsletters would be a good approach.

• Paul encouraged the group to look at the website for updates. Every week the Arkansas Hospital Association has a "Thursday Mail out", which is a hard copy of information, such as, federal registers, letters, or what ever is needed. If copies of information that is important such as this, we can always include them in the AHA mailings and know that the CEO’s receive a copy.

6. EDI/HIPAA – Kelly Vaughan

• We are focusing on 835 Electronic Remits because we still have some providers who are receiving electronic remits in a non-HIPAA compliant format. CMS has not issued a deadline that requires all remits to be in the HIPAA compliant format. We have still not received a deadline on the contingency plan for the 837I and the 837P.

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• A handout was given on "The HIPAA Report User Guide". This guide was created because of provider requests for some sort of aid in reading and interpreting these reports. Kelly asked the group to be aware of the levels of reports that are available for the providers. On page 3 of the HIPAA Report User Guide you will see a section on the different levels of editing.
  
  First Level: TA1 Interchanging Acknowledgement Report is only available if your software is coded to receive this report. It also okay if you are not able to get this report. This report edits for CENTAX or the format for the interchange header Trailer.

  Second Level: 997 Functional Acknowledgement Report is received by everyone who sends an 837I or 837P HIPAA compliant transaction. If you reject at this level (A=Accepted and R=Rejected) then you will have to fix your file and resend it to us. You will have to contact either your clearinghouse or your software company. EDI or Medicare Services cannot assist you in correcting your errors at this level.

  Third Level: Batch Processing Report or BPR is for people who have AHIN workstations. You can go out on your workstation and pull this report. You will dial into the gateway and download this. It will tell you if you are passing our front end edits at EDI services. You can find instructions on page 12 of the HIPAA Report User Guide. This is one of the most important reports you will use. This report shows you how many claims have been received or rejected with the dollar amount. They are available within two minutes after the file is transmitted or 30 minutes depending on how many files we have coming through. If you have claims to reject you can pull that report and correct the claims and resend them. If they are rejecting at this level then the error has occurred within your office.

  Fourth Level: At this level there are different reports for Part A providers. You have an acceptance report and a reject report. For Part B you have the Batch Detail Control Listing (H99).

• Kelly stated that the User Guide will be placed on the website. Paul suggested that when it’s placed on the website if they could place a pop up notice concerning this as well.
• For those providers who use clearinghouses please be aware that your clearinghouse is the one to receive the report. If you have not received a check in a while you might want to first check with your clearinghouse. Your clearinghouse should send you a copy of the acceptance report. Please request this report if you are not receive it currently.
• Remember that when you send your claims to your clearinghouse today that doesn’t mean that the clearinghouse sends them to Medicare today. When you are counting days on the payment floor you need to know the day your claims got submitted to Medicare.
• Greg asked if the group had any further suggestions or recommendations in this area, there were none at this time.

7. Inpatient Rehabilitation Facilities Probe – Dr. Sidney Hayes, Susan Moore, and Wynne Dee Throop

• Dr Hayes stated that in the last few months we have undergone evaluations of the inpatient rehab facilities in the state of Arkansas. This probe will give you an idea of where we need to go and what is going on. There are a lot of discussions nationally about the 75% rule which has caused a lot of the states and FI’s to works on Inpatient Rehabilitation Facilities (IRFs) at this time. CMS is required to insure that payment is made for reasonable and necessary services. They contract with carriers and FIs to perform data analysis on claims to identify a typical billing. We then must determine if the billing problems exist and we do this by conducting probes. Through data analysis it was revealed that it was high utilization of Code B and C Tiers. These represented the highest rates of reimbursements.
• Susan stated that during the PROBE they were looking at the top providers who billed for IRF services. The size of the facility was not a factor nor was the average length of stay. We looked at those who bill with the B and C HPSA codes and had the highest dollars billed. Dr. Hayes stated that the selection criteria shows that we looked for bill type, revenue codes, B or C HPSA code, and also top ranked providers. Claims were suspended randomly on a prepaid basis for periods from January 1 – June 30. Medical record requests were generated and sent to the facilities for those claims that were suspended. Each provider had 45 days and then the claims were reviewed and they either paid or denied based on the documentations proceedings. There were 101 claims suspended for review. Out of all the IRF providers 17 providers selected. If you were a large facility you were most likely selected. Out of the 101, 17 of the medical records were not received in a timely manner. Claims without documentation were denied. Out of the 84 remaining claims to review, 25 were considered inappropriate admissions to the IRF by Medicare guidelines. Out of the 101 claims we had, 89 were denied and only 12 were approved for reimbursement. This was for Pre-Pay. Out of the 89 denied, 47 were for inadequate documentation, 25 were for inappropriate admissions, and 17 were no response to the request.
• This probe help to determine that education is needed for all providers within the state. There are some that need the one-on-one education. This has been initiated. Letters have gone out about the appropriated documentation requirements. Dr. Hayes stated that looking at the numbers we could suspend up to a quarter of $1billion dollars. We need everyone’s input on how else we can deal with this within the state.
• Paul wanted to know under the admission criteria were the inappropriate admissions based on the 75% rule. Dr. Hayes stated that it was basically inappropriate admissions for people who could not go to PT/OT. They should have been receiving acute care.
• We are holding an Inpatient Rehabilitation Workshop on November 16, 2004 and letters have gone out to the CFOs of each IRF.
• Susan stated that the purpose of the PROBE is validation of educational needs. When we attended the regional meeting in Dallas, TX we discovered that this is an issue among all contractors.
• Paul asked for an update on the issue of the draft LMRP. Dr. Hayes stated that information concerning this has been posted on our web-site for over a year.
• Susan stated that the PROBE is not an audit. It randomly suspends 101 claims. This is approached from an educational standpoint. We will recheck our numbers and see what our data analysis shows us and then we may have to go to an audit. Paul stated that whenever a notification is put together he would like to assist in getting that information out.

8. Section 921 MMA-Provider Customer Service Program (CR 3376)

• This section of the Medicare Modernization Act states that we need to strengthen and enhance Medicare through ongoing efforts associated with provider inquiries and education. There are several areas that are addressed. The part concerning customer service will be addressed later on in the agenda.
• CMS has asked that we post Frequently Asked Questions (FAQs) to our web site. We are gathering these questions from workshops as well as service calls and correspondence. Greg asked the group if they felt this would be helpful.
• We are looking at revamping our web site so that you can access information easily. We are working to develop a separate Medicare Part A section on the web site. More web based courses will be forthcoming as well.
• CMS has also asked us to tailor training to the small providers. The facility side should have less than 25 full-time employees and the physician side should be less then 10 full-time employees. On the physician side a lot of them are not connected to the internet. Greg stated that any input on how to identify small providers would be helpful.
• A representative asked if this new Change Request (CR) is pushing providers to hire certified coders. Greg stated that it has asked that all contractors have a certified professional coder added to the staff.
• Greg solicited the help of the group in helping to develop an open door forum among the provider community similar to the CMS Open Door Forums. Paul and several others agreed with the idea of the open forum. Amanda asked if any of the providers present had participated in any of the open forums and a few stated that they had. They agreed that they were very informative. We will also be using our data analysis to target providers that need help in reducing their claims submission errors.

9. Audit and Reimbursement – Amanda Crosby

• Provider Audit: Psyche and Rehab units in Critical Access Hospitals (CAH). CMS sent a letter to states agency directors. A PPS hospital with a PPS excluded psyche and rehab units that meets criteria as an IRF may convert to CAH status with the same distinct part units at any date on or after Oct 1, 2004. A current CAH hospital wishing to add a distinct unit can add a distinct unit at the beginning of a CAH cost reporting period on or after Oct 1.
• We have had several questions concerning the contractual amounts on RAs. For the hard copy version of the RA the contractual may not be correct on the RA. If you have claims for which the charges are less than the APC the contractual on the line item is going to be negative. This is causing some providers when they go to post these amounts onto their systems.
• TOPS for sole community providers may not be paying correctly. We won’t know until we receive the payments. We want you to be aware that there may be a problem. We will also place a notice concerning this on the website.
• Amanda stated that we are launching a project to update permanent files. We will be starting with the hospitals first. We will be sending letters requesting specific information. We are asking that you please assist this and respond to the request when received. We are trying to get this out by the end of October 2004.

10. Hearings and Appeals – Rhonda Cordon

• Effective Oct 1, 2004 all reconsiderations, and all first level appeals and reviews has been named redeterminations. This has been placed in an article in the newsletter and this has been placed on the website. The formats of your reviews and reconsideration letters are going to be different. More information has been included.
• Effective October 18, 2004, CMS has released a listing of who the QIC contractors will be. Oct 1, 2005 is the projected implementation date.

11. Claims – Sara Phillips

• Sara stated that the claims department now has a new trainer Carl Carter who is in charge of Provider Education for the Remote system. If you have any staff needing education or a refresher course, please have them call the service line and he can schedule them in upcoming classes.
• Providers were encouraged to review the MedLearn Matters. The MedLearn Matters are written especially for providers, eliminating the contractor taskings and concentrating on the issues of interest in this notice for providers. MedLearn Matters are listed on the website, www.cms.gov/medlearn/matters, beginning with the most current release.
• In the 4^th quarter alone we had over 100 phone calls concerning the G adjustments. The adjustments are all caught up and they are being kept current. If you have any problems with them please have your staff contact our service line.
• Our claim specialists have 20 days to fix a claim once it enters our system. We are seeing a lot of claims where we get calls stating they need help and they don’t know why it’s being suspended and they want it worked as soon as possible. The claims are worked and they have to age in the system. We are asking that your billing staff not call if 20 days have not passed. If they are having problems then they will need to contact the trainer so that he can assist them.
• Effective Oct 1, 2004 outpatient claims were not suppose to contain the procedure codes and they were supposed to reject. A fix went in on the October 14, 2004 and they will be released at the end of the month. They will automatically reject instead of returning back to the provider, which they can’t do anything with them anyway. CR 3264 explains all of this.
• Section 921 MMA-Provider Customer Service Program (CR 3376) for customer service is a major change. Customer Service Representatives will be split and dedicated to either providers or beneficiaries’ issues. They will further be split into a Tier 1 and a Tier 2. The calls will go to a Tier 1 and if they are unable to answer your question it will then go to a Tier 2. If they are not able to help you then you will go to a specialist. You will not be able to call in and talk to a specific person anymore.
• The Interactive Voice Recognition System (IVR) will provide claim status about beneficiaries’ eligibility and at least the Top 100 RA codes and definition.

12. MSP – Sherry Price

• A few errors were noted during the audit process. The value code 44 and the occurrence code 18 and 19. Most hospitals were not aware that they need to the value code and the two occurrence code on their billing. Sherry brought handouts for the members to take back and share with their staff. These handouts are great for your billing and admission staff. It was recommended that this be included in a newsletter article.

• We are paying all prepay Part A claims in a timely manner. We are developing on the website all of our audit numbers. We will put a description as well as a listing of all the documentation that will be required for each audit. This should be posted in the next several months.

• The OIG has released more information about compliance plans for hospitals and just recently they also released their 2005 work plan.
• The October 7, 2004 Federal Register included corrections to the Hospital Invitation PPS and Fiscal Year 2005 rates.
• The tentative dates for our 2005 meetings are January 12, April 20, July 20, and October 26.
• Greg asked the group if they had any other question or comments. A representative asked how can other people who wish to attend this advisory meeting be added to the invitation list. Greg stated that the initial group consisted of representatives from each of the Arkansas Hospital Association districts and has been expanded to be sure to include the various types of facilities as well as related agencies or groups. We try to address whether we should add rural hospitals, urban rehab, and critical access hospitals. We will be happy to speak with anyone if they are interested and see if this fits into what they need. We do have a limited amount of space. CMS has stated in their guidelines that they wanted the providers represented and as well as consultants and billing personnel. A representative stated that this was his first meeting and it has been very informative and he could not imagine anyone not wanting to attend a meeting such as this one.

The meeting was adjourned at 12:30 p.m.

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