Agenda

• Guest Introduction- Pam Kanawyer from the Dallas Regional office of CMS.
• EKG Policy AC-008- EKG and Related Cardiac Studies- Change to inaccurate V code
• Corrected Claims Issues- Results Recognized From Corrected Claim Letters
• 2002-03 Immunization Season Update- Kim Gassie
• "Medicare Proposes 2003 Physician Pay Changes Standards for Physician Data input Eased"- Merle Francis
• Current Data Analysis Results of 2001 Specialty Workshops
• Open Discussion- All
• Conclusion

July 25, 2002
10:00 a.m.

Present: Merle Francis, ABCBS; Kim Gassie, ABCBS; Casey Brown, Stanocola; Kelly Rivet, Baton Rouge Clinic; Darla Landry, Medicaid Program Operations; Dr. Lynn Hickman, ABCBS; Cheryl Green, ABCBS; Sheila Plummer, ABCBS; Ken Endsley, AASI; Michelle DeSoto, ABCBS; Mary Leiux, Unisys; Shan MacDaniel, MDS; Jack Olden, LHCR; Charlene Breaux, LMGMA- Urology Clinic; Jennifer Sumrall, Trispan Health Services; Cathy Hollaway, Trispan Health Services; Margie Slaughter, ABCBS; Ragan Canella; LSMS; Diane Caldon; ABCBS

Guest: Pam Kanawyer of CMS

This meeting began at 10:00 AM with introductions of the members and introduction of our visiting guest Pam Kanawyer of the CMS Dallas Regional Office.

LMRP Policy Issues:
Dr. Hickman discussed four LMRP issues.

Cardiology - EKG
In the policy published in the Medicare Provider News of March 2002 (AC PN 2002-01, attached for your review), V81.2 (special screening for other and unspecified cardiovascular conditions) is listed as contained in the original Missouri LMRP. The code is to be used for Pre-operative evaluation of patients with known cardiovascular disease. This V code is not accurate. The CMDs have added V72.81 (other unspecified examinations, pre-operative cardiovascular examination) to the Policy, as this code is more appropriate. The provider communities should begin utilizing V72.81 for pre-operative evaluations.

Both codes will be allowed for six months and then we will be removing V81.2 from the Policy in December. January 1, 2003 will be the effective date.

Merle asked the committee’s opinion on what we should do to ensure the proper education of the cardiology code. Dr. Hickman stated that we are open to suggestions. The August Newsletter will not be in print and will only be available on the website. This is something that will be covered in the December cardiology meeting by Dr. Hickman also. The committee noted that this service is not just billed by Cardiologist and suggested a message be placed on the R/A’s to alert all providers to this change.<ACTION ITEM>

We are getting a lot of claims in a short period of time and Dr. Hickman and the other CMD’s are concerned about the frequency of treatments. This policy is in effect in all 5 states and is very vague with regard to the appropriate parameters for treatment. This is not covered in our current policy however; it should be addressed to ensure the provider community is aware of the expected frequencies of treatment. We are going to submit questions regarding frequency and intervals for the appropriate treatment to the Medical Board in the next two weeks. This information should assist us in making the necessary revision to the existing policy. The revised policy will not be sent to the CAC but will be published on our website and in the Provider Newsletter.

Input was requested from the PCOMAG on how best to meet the educational needs for the providers currently billing for this procedure. It was suggested that a direct mail notice be sent to the providers identified through analysis, that are currently billing this service once the policy revisions are made. This targeted direct mail piece would prevent additional cost in mailing a notice to all ophthalmologists. <ACTION ITEM>

Dr. Hickman stated that the March Chiropractic Newsletter makes a reference to "maintenance" as a "non-covered" service under Medicare, reference MCM 2150.b2. The policy as published is incorrect and should be revised. Maintenance therapy should be denied as "not medically necessary" and therefore would require an Advanced Beneficiary Notice from the patient before treatment occurs if the patient is to be financially responsible for the services.

Merle stated that we are planning to conduct an October Chiropractic Workshop, separate from the LA Chiropractic Association. This separate meeting will allow us to reach those providers who are not members of the state association. The revised policy will be the focus of the workshop in October.

Jack Olden concurred with the educational plan.

Jack asked if there were going to be multiple sites for these workshops?

Kim advised that we anticipate approximately 500 providers will attend the Chiropractic workshop. Michelle is conducting an analysis to identify the locations where the majority of these Providers are located and we will choose the three more concentrated areas to conduct the ½ day workshops.

Merle asked the PCOMAG about their opinion on conducting a Focus Group where we would invite 10-20 of the top billing Chiropractors to meet with Dr. Hickman and some of the other staff regarding the policy and utilization of services. The focus group approach would give us the opportunity to address specific billing patterns and utilization of the providers in attendance and also, compare their billing patterns to their peers. It would also give us an opportunity to measure the effectiveness of our workshop.

Merle advised that part of their ongoing training had included the CAC representative for Chiropractors providing an "in-house" training session to go over the terminology, coding structure, etc… with our internal staff at every level, to ensure our thorough understanding of the claims submitted by Chiropractors in Louisiana.

Removal of HCPCS codes is a standard procedure and does not require a policy to go back through the CAC process. Our standard procedure is to publish a policy revision or simply note the deletion of the HCPCS code. Because there is a high utilization of steroids in Louisiana, Dr. Hickman felt that some special education might be necessary with regard to this code deletion.

Dr. Hickman stated that it is going to the CAC in August and will be effective in December.

Merle asked the PCOMAG if a direct mailing should be done to those providers billing this code? The PCOMAG concurred with this plan, as did Dr. Hickman. Dr. Hickman feels he would like to share the information with our other four other states as well, for their use in educating the providers. Merle advised that the direct mail letter would be shared with the other states through the minutes and as a part of their PET Process Improvement Team efforts in coordinating education.

In conclusion it was decided that these matters would be handled in the following manners.

1. Cardiology- EKG Policy- a RA message would be sent out and information will be included in the December Cardiology meeting.
2. Chiropractic- Inclusion of policy changes in 3 statewide workshops and one Focus Group after the workshops are concluded.
3. OPT with Vertiporfin- Direct Mailing to the providers who are currently billing this service. The educational piece of correspondence will be shared with the other PET sites for use in their areas.
4. Data Analysis of utilization of J0340 for most recent 6 months of claims history to determine who a direct mail letter should be sent to, announcing the deletion of J0340. Direct mail letter would be shared with other PET staff for use in their educational interventions.

Inclusion of the minutes of this meeting will be on the website as usual, and will allow any provider to review the discussion of these issues as well. Additionally, these minutes are shared with other ABCBS Provider Education and Training (PET) areas for their review and information.

Kim Gassie reviewed the handouts that were provided. Included was a page that contained a link to the June 25^th First National Immunization Conference Call for QIO’s held by the Infectious Diseases QIO Support Center of Oklahoma City, OK. The handouts for this call can be found at this link:

For those without access to the QIOnet these handouts can be found at:

A print out of a Power Point presentation by Carolyn Buxton Bridges, MD of the National Center for Infectious Diseases was also provided. This handout covered the 2002 ACIP Influenza Vaccine Recommendations

Jack Olden provided a handout titled " Influenza Vaccine, What you need to Know." This handout is the same one that will be distributed to Physicians Offices, Pharmacies and Hospitals and is for the public to view.

Jack told us that there are 92 million doses of Influenza Vaccine available to distribute but the big question is "When?" It is imperative for the Physicians to reserve the vaccine early. Last years vaccine was all booked by May. This year, Vaccine is still available and can be reserved on the CDC website. Kim stated that a link to this is on our website as well.

Jack asked if we have heard anything about the reimbursement of the Vaccine yet.

Merle read from the handout dated June 27, 2002 titled "Medicare Proposes 2003 Physician Pay Changes Standards for Physician Data Input Eased." that will be posted in the July 28 Federal Register.

…"The proposed rule would also nearly double the Medicare payments for administration of some vaccine immunizations from $3.98 to approximately $8.00."…

Merle asked Jack how are the immunization rates comparing to last year?

Jack told us that they look at both Influenza and Pneumonia. Pneumonia has risen to almost 19% in over 2 years. There is no shortage in this vaccine. It can be administered year round. Flu however has gone up 60-64%. There is still a lot of vaccine available. Jack feels that we need to educate patients about this and by creating a sense of urgency through ads on TV/Radio, it is helping some.

Merle talked about the Richard Baker Social Security Symposium scheduled for August 23^rd. It will be held in Baton Rouge at the Pennington Center. Merle will be presenting information to those in attendance on Medicare Preventative Services. She will include information on flu shots and pneumonia shots to assist in the PRO’s efforts to educate the Medicare Beneficiary population. The LA PRO will be sharing a booth with Medicare Part B for this event.

Merle further reviewed the June 27, 2002 Handout reminding the PCOMAG of the significance of commenting on the physician fee schedule proposed rule. This will update physician payment rates under the Medicare physician fee schedule for 2003, as well as revise a number of other policies affecting Medicare Part B payment for physicians and other providers."

Anyone wishing to comment on this Federal Register can find instructions in the register on how and where to comment. This information is usually located on the last page of the document.

Pam Kanawyer stated that this is a very high priority with congress and that an effective way to comment would be through your organization. "Voices are louder in numbers."

We are working to keep the providers informed as much as possible and as up to date as possible. Providers do not understand that our Customer Service Reps are as well informed as the Field Reps and providers are not willing to speak to them or allow them a chance to answer their questions. Providers are constantly finding a way to get around Customer Service and are only willing to speak to the Field Rep that visited their office. We continue to stress to providers that they are only prolonging the time it takes to get answers to their questions using this route.

Merle asked the PCOMAG if eliminating the terminology " Field Representative" and the association of assigned "territories" would help the provider community change their behavior. She suggested the term "Education Staff" be used in association with the Provider Education and Training staff members.’

Kim stated that we believe that this will give the Providers more of a sense of our "education department" to cover the whole state rather than a one on one person to cover an area of the state. This may allow providers to be more willing to discuss their inquiries with the most available Customer Service Representative in lieu of insisting on a member of the Provider Education Staff. This will also assist the contractor in the transition to reduce the staffing levels as necessary, based on preliminary Reverse Funding targets received from CMS.

Merle mentioned that with the staffing decrease from four Field Reps to three in October, will require us to redirect our type and volume of education to the providers in Louisiana and will certainly eliminate some of the services we provide to our provider partners today.

CMS has provided us with a different kind of budget this fiscal year which will necessitate a reduction in staff in the Provider Education and Training area. This reduced funding will affect the volume and types of provider education available to the providers in Louisiana. In an effort to gage what type of provider education is perceived as most beneficial, we conducted a provider survey during the recent LMGMA annual meeting. The results of this survey were presented to the PCOMAG for discussion.

Provider Specific Education had the highest rating with 34% preferring this method of educational interventions. This was followed by Comprehensive Educational Interventions as the second choice, scoring 22%. The survey and results are attached for your review.

With more and more emphasis on using our current resources for provider education, efficiently, we have begun measuring our efforts for effectiveness. Handouts were distributed to provide an analysis, conducted by Michelle DeSoto, of the effectiveness of the most recent Provider Specialty workshops conducted in Louisiana. The graphs identify the claim rates from January-June 2000 that was used to target these specialties for education. The average denial rate at this point was 20%. Upon conclusion of the workshops a new analysis of the same areas from July- December 2001 indicated a considerable drop in denial rates to 17%. Our overall conclusion was that these workshops had been effective and were successful in accomplishing a reduction in the denial rates of claims. The PCOMAG concurred that this measurement indicated an effective educational intervention.

Merle suggested additional measurements as a possibility for future interventions. Jack, Shan and Casey all indicated that they felt measurements of the specific providers in attendance would be beneficial and provide an indication of our effectiveness with the individual providers. The PCOMAG members concurred and recommended that this type of analysis be done in addition to the analysis done on the specialty as a whole. Merle advised that this would be taken into consideration with the resources available.

The attendance for these workshops is on average an estimated 80 providers. Merle asked whether a random sampling of those providers in attendance should be done or should we take a percentage for analysis. In response, the PCOMAG suggested the use of a statistician. Merle advised the group that the only statistician available is in our Little Rock medical review area with a full time workload. Pam Kanawyer suggested a random, statistically valid, sample be used for the analysis.

Shan McDaniel suggested that the data be broken down by specialty first and then take percentage of providers in attendance from the more refined data. The PCOMAG recommended we determine the % of attendance to the type of provider and use this as a basis for our post educational analysis.

Casey Brown suggested that we also need to compare the attending providers to the providers that are not attending and provide this information to the entire provider community. Merle suggested that we conduct the analysis and announce the findings in the next available Newsletter. Pam Kanawyer stated she thinks CMS is more interested in the delivery of effective educational interventions rather than the higher volume of ineffective interventions.

Merle discussed the fact that with budget and staffing changes imminent this year and in the future, instructions are going to be different as to Local Medical Review Policy and our Provider Newsletter format. We will rely more on the website to disseminate much of our information. Our Newsletter will consist of summarized information with links to the web site that will provide more in depth explanations of the Newsletter topics. This will force people to get in the habit of going directly to the web site for information. This will allow us to post correspondence on the web site with the knowledge that more and more providers will be visiting on a daily basis. Thus, ensuring uniformity on the information that is given out.

The next topic that was discussed was inquiries and correspondence that is received through the Website Feedback email address. Currently these emails are treated as routine correspondence in Customer Service. They are printed and placed with paper inquiries that come in through the mail and handled as "routine correspondence". Recommendations were asked for by Merle as to the best way to let the inquiring person know that we did receive their inquiry, it is being addressed and they will receive a response from our office in a specific timeframe.

Jennifer Sumrall and Shan McDaniel suggested that we place an automated response on the email that explains the response process, time frame to expect and method of response anticipated.

John Warner added that a reference to the web site’s search capabilities may also help to eliminate the amount of provider inquiries since most or all of the information can be found on the web site if the time is taken to research what is available.

Margie Slaughter will check with Sport to see if this is already done. If it isn’t she will take the necessary steps to implement it as soon as possible. Everyone agrees that the auto response is a good idea that will allow us to respond and inform the providers about the response process.

The PCOMAG asked if email responses could be provided to eliminate the need to incur the expenses for postage, printing and supplies used to respond via letter. The PCOMAG also stated that the electronic response is their preference over paper because it would allow them to route the response to many different staff members within a provider’s organization.

Margie explained that currently, our Customer Service Representatives do not have PCs to allow them to respond directly to email inquiries. We expect installation by the early part of the next fiscal year and will give some consideration to this method of responding in the future.

Pam Kanawyer thanked everyone for his or her support during these meetings. She has received valuable input to bring back to the CMS corporate office. Pam distributed a handout that outlined the purpose of the PCOMAG and contained information about the CMS Open Door Forums. She invited everyone to participate in the open door forums and referred the PCOMAG to the Internet for updates and schedules for these events.

Pam updated everyone on CMS’ efforts on HIPAA. She indicated that CMS is working with vendors to ensure that they are on top and moving along with HIPAA implementation. Pam also reminded us that there will be no paper Claims as of October this year unless and extension is requested by the providers. Merle stated that currently, over 85% of LA claims are submitted electronically and the other 15% have ten or less employees and should be exempt form the HIPAA requirements for electronic claims.

Mary Lieux stated that Medicaid has hired two new Reps for the Central Louisiana and Houma, Thibideaux areas. Medicaid is experiencing the same problem with Providers only wanting to deal with Field Reps rather than speaking with customer service. As of Monday, July 22^nd they have implemented a new process using an "Internal Field Rep" staff member to answer telephones to assist the Field staff. Mary provided a handout identifying the current Medical Staff members.

Mary gave out a schedule of the upcoming Medicaid workshops and encourages attendance of providers. She also outlined where Medicaid was on implementing the Community Care Program. There will be a Secondary Provider Workshop in Alexandria that is open to any provider. There will also be an Individual Community Care Workshop.

Jennifer at Trispan is also having trouble with providers not wanting to use Customer Service to answer their questions. Customer Service Representatives (CSR’s) need to be as informed if not more than the Providers are. Merle pointed out that the CSR’s at LA Medicare are required to attend the workshops in house prior to the workshops being provided to the Providers. Darla suggested that we share our frequently asked Questions (FAQ’s) from the workshops with the CSR’s. This will allow them to see which type of questions they may be asked and provide them with the correct answers.

Kim Gassie discussed an issue that has continued to be problematic over the last two years. Providers have been sending in claims marked "corrected claims" suggesting that a review be done on the claim. In response to this inappropriate filing method for requesting an appeal (review), we have taken actions to educate the providers on the proper ways to request a Review. In February we sent out a mass mailing to 45-50 physicians who had been identified through our analysis, as needing education on the correct filing procedures for appeals. These direct mail communications provided detailed instructions on the proper way to request a Review. The most recent analysis of the providers, who continue to use the "Corrected Claim" method, revealed that the providers, who received the direct mail education in February, did not show up on the new list. This would indicate that the direct mail has been effective in changing the billing behavior of the providers notified.

Conclusion:

This meeting concluded at 11:45 am

Next PCOMAG meeting is scheduled for September 26, 2002 at 10:00 AM in the 3^rd floor conference room of the LA Medicare Part B Office.