The Louisiana PCOMAG
Meeting Thursday, June 17, 2004
Attendees:
In Person: Amy Brunet, Baton Rouge Clinic; Sylvia Doggette, ABCBS; Kim Gassie, ABCBS; Diane Groh, AASI; ABCBS; Susan Taylor, LMGMA; Gayle Hill, OK/NM ABCBS; Debra Boudreaux, ABCBS; Robin Hutchinson, ABCBS; Diane Weiss, ABCBS; Shan McDaniel,
MedData Services
Guests: Pam Kanawyer; CMS Dallas Regional Office; Michelle Smith for Dr. Hickman, ABCBS Medical Review
Teleconference: No one took advantage of the teleconference capabilities today.
Minutes Taker: Diane Caldon, ABCBS
Welcome
Recognition of visitors, new members
Pam Kanawyer of CMS Dallas Regional Office joined us today in person. Michelle Smith also joined us on behalf of Dr. Lynn Hickman who was out of town to attend the PCOMAG in New Mexico.
LCDs- Local Coverage Determinations
Michelle came to discuss questions that providers may have about the Local Coverage Determinations (LCD). She explained the new format. The are now two hundred consolidated policies to complete. Fifty-three are complete to this date. Michelle hopes
to have the balance completed by December 2004.
The policies will continue to include the CPT and ICD-9 codes. Policies are on our web site.
Another update that we have added is the short descriptors to the CPT codes. If you look at some of the short descriptors, they are difficult to understand. Providers do not like this. It was not our choice to do this. Our nurses and staff must go
through the same procedures as the providers do to find the information.
Michelle feels that on eof the biggest issues is that this happened so quickly as far as the providers are concerned and they did not know it was coming.
Suzanne Taylor was also surprised at this change. She feels that we are still going to hear from providers about this because the information is out there but providers are just slow to discover it.
Kim Gassie asked the PCOMAG if they had any suggestions on which other avenues we should use to get the word out to providers and easing them into this change.
Shan McDanel suggested that she felt that it was happening all at once and providers have not had a chance to digest the transition yet.
Michelle explained that each one is large volume and coming from her standpoint. We were determined that we were going to finish the consolidation process and get it done, so we did not have other issues coming up. An then, they were instructed
with two weeks notice that their would be no more LMRPs. By this point, we had passed of them out there for drafting.
Michelle explained that there are NCDs, which are National Coverage issues. Their processes belong to CMS. Then there are our LMRP that is Local. If they were not crosswalked over to the LCD, then they were retired. We did have some delays in
completion due to the volume.
Robin Hutchinson explained this was her concern she was not clear on how this was happening.
Diane Groh expressed that she is still receiving denials as recent as one month ago. Michelle told her that she needs to let Medical Review know about them because there is obviously something in the system that was not visible to us to get it out
there. Most of the times they go in and end date it.
Diane Groh asked if Michelle thought if all of them are indeed retired and she should not get anymore denials for the LMRPs.
Robin explained that some of them have term dates and others were just removed altogether so, it would depend on that.
Michelle explained that if Diane is getting denials on the list then she needs to know about them. When she does not hear about it directly from problem areas then that is when she does not hear about it from Robin’s area, she hears about it after
they were denied. Then Michelle will need to follow up on them at that point.
Diane Weiss explained that she has worked with a provider on a similar issue and the dates of service were well into 2004. Michelle Smith stated she needed to know about them as well.
Diane Weiss suggested creating a link in the LCD were the provider would have direct access to further explanation. It would still be contained in the LCD with a link to further information.
At this point, there are no articles for the LCDs. If we do write an article then we will link them on our web site. It will be linked within the LCD itself.
Results: Kim will work closely with Michelle Smith to create a flow chart. We will send the flow chart to our Top100, PCOMAG and post it to the web site.
WBT Course: Kim ask the PCOMAG if they felt we should wait on one of the Web Based training Courses that is on LMRPs. Michelle recommended waiting for everything to be final.
Result: The WBT team will place the LMRP course "Under Construction" until this all becomes final. Let the provider know that we are updating it. We hope that by the end of the year will open it again with full revisions.
We will get this info on the web site and to the list serves.
Updates
PCOM Advisory Group Attendance –
We are looking at adding new members to our PCOM Advisory Group for the Louisiana office. We have been approaching members of Medical Societies and Associations. We would like to see more participation from the Specialty Societies. Medicare would
like to see more representation in the Louisiana office. For those members that are active in their specialty societies, if they think of somebody or know somebody that they would like to recommend, please contact Kim Gassie.
Shan McDanel knows of an Anesthesiologist that would be a great addition to the group and would email the name and telephone number to Kim.
For providers that are not yet billing in an electronic HIPAA approved format, we currently are paying them on a 14-day payment floor as we do with electronic submitters. We believe this is CMS’ attempt to get providers to complete their testing
and become HIPAA compliant for their electronic submissions. We are changing the payment floor on these electronic claims. We have sent out a number of things to inform the provider.
In an educational effort to inform the provider community about billing in a HIPAA compliant format, CMS has sent a letter to providers that have not yet completed HIPAA testing. We have also posted the information in our newsletter. The letter is
dated May 14, 2004. It tells them that they will now be going to the same payment floor that we have for paper claims which is 27 days.
The final paragraph of the letter is as follows:
"It is expected that CMS will end the contingency soon after July. Once this has occurred, we will ACCEPT ONLY HIPAA compliant claims. All other formats will be rejected and no payment can be made. In addition, if you receive
Electronic Remittance Advice (ERA) today, you should be converting to the HIPAA 4010A1 835 transaction. Once CMS ends the contingency plan, no other ERA format will be sent by Medicare."
Kim asked the PCOMAG if they had any suggestions as to how to push these providers to come through and begin testing. We have talked to them in seminars, published in newsletters and the on the web site. Customer service has also talked to
providers about it.
There is a misconception that we will not be accepting paper claims at all. We have given providers a large article in the May newsletter on the eleven exceptions for anybody who can still file and further defined the "small provider."
Robin suggested that providers are under the misconception that CMS will never do anything about it if they do not begin billing in a HIPAA compliant format. She thinks this is because they extended the deadline then came up with a contingency
plan. Providers feel that CMS will never stop accepting their claims.
Shan McDanel from MedData Services has noticed from her experiences that some contractors i.e. Medicare and Medicaid interpret the HIPAA requirements differently from one another.
Pam Kanaywer from CMS asked, "In what way are they misinterpreting?" Answer: File transmission, grams vs. pounds, etc... .
Diane Groh of the Ambulance Liaison Committee agreed that there is too much room for misinterpretation. Arkansas Blue Cross and Blue Shield interpret the requirements very different form the way that Mississippi does. Some of the things that
Arkansas wanted in some fields were different then the contractor in Mississippi. It took the programmer a long time to get the correct information.
Suzanne Taylor expressed her concern for providers that still do not have computers. Diane Weiss of the Provider Education Department of ABCBS questioned if very small providers will be able to continue to bill paper claims.
Kim Gassie asked the PCOMAG if they felt that the change to the payment floor was any incentive for providers to begin billing in the HIPAA compliant format.
Diane Weiss commented that she has spoken to providers that have said that they do not care that they will be dropped to a 28-day billing cycle. It just means they will have to adjust for a month or so and reformat their own billing cycle in house.
This letter warns providers that the contingency plan will go away. The PCOMAG feels that if the provider has a specific date that tells them that after which CMS will not accept non-HIPAA compliant claims at all, then they would not be so
unworried by the fact they are not HIPAA complaint. We have tried to give them as much opportunity as we can.
Suzanne Taylor mentioned that she heard that we are changing the frequency of the checks. Kim said she had not heard this but would check with Mr. Bradshaw to see if he may wan to send out a follow up on this. We will send a follow up to the
PCOMAG about this.
Kim Gassie has been asked to speak at the EDI vendors’ conference in New Orleans about duplicate submissions and the problems that it causes with providers. She has been given a 30-45 minute timeslot. Providers are not invited to this conference.
Only submitters will attend.
CMS did publish a Medlearn Matters notice about a month ago (see link above) that explains the delays in processing enrollment application into the Medicare system. In continued efforts to decrease the backlog of providers, we have also been asking
our specialists to work overtime. Enrollment has also changed the way that supervisors distribute their work. We have also staggered the working hours in provider enrollment do that there are not as many specialists on the nationwide database at one
time. This will help to speed up the amount of hold time in between data screens and to improve the processing time slightly. A detailed letter was included in the May 2004 newsletter.
Diane Groh of Acadian Ambulance asked to whom she should send a letter of appreciation. A member of the Provider Enrollment staff for the wonderful experience that she had with one specialist recently. The Specialist was very helpful and patient
with her during her activation of a new provider number for the new company that they opened in New Orleans. The person to contact is Pat Gianelloni with CC to Merle Francis. As the Supervisor of Provider Enrollment, we understand that Pat and her
staff are under much pressure to catch on the backlog and they would love to hear words of encouragement like this.
OCR – Optical Character Reading – There is a new PO box for Paper claims. An article has already been written and should be in the next newsletter. We will also like to send it out to the TOP 100 and ask them to assist us in getting the word out
and they can share it with their Associations and group. It will be very critical after the specified date, that providers begin to send their paper claims to this PO Box. If the group comes up with any other suggestions, after it is out, that will
help to get the providers rolling with it, Kim will be happy to implement their suggestions.
We are staggering each state to make sure we get each state up and running before we go on to the next state. Louisiana is due to begin in July. Missouri is working very well with it now. The March 2004 Newsletter provides and excellent source of
information for this.
We have moved all telephone calls and instructed all patients to 1-800-Medicare for all questions about the prescription drug card. A handout was provided of the Medlearn Matters and an article was posted in the May Newsletter. Beneficiaries should
have all of their prescriptions ready when they call and a customer service agent will help them to choose the best prescription drug card for them.
We have been talking about this in Workshops to providers, and at the LMGMA conference in New Orleans, asking that providers share this with their beneficiaries.
There are brochures available for download of the CMS web site. Kim did share this with the LMGMA. She encouraged providers to go to the CMS web site and download the brochure to include in their offices. The PCOMAG was welcomed to do this as well.
Handouts were provided and the PCOMAG was asked to help us educated providers about the Comprehensive Error Rate Testing (CERT) program that CMS started. CMS has contracted with a group called Advanced Med. Advanced Med is actually the contractor
that is looking at us as the carrier to make sure that we are processing claims correctly the first time that they are processed. We have talked about CERT before. Kim explained the CERT process as follows:
The CERT contractor will come to us as a carrier and ask for a sampling of claims. We supply those claims top them. Then Advanced Med will go out to the provider community, via a letter, asking for the documentation to substantiate the medical
necessity for those claims.
We have had a very large problem with providers not responding to those letters. We have talked about this before, put out articles on web site and in the newsletter, talked about in workshops and in all of the educational efforts that we do. We do
not know what else to do to get providers to respond.
We also have gone to calling providers if Advanced Med has sent out two letters to the same provider and it has been at least twenty days. We are contacting the providers letting them know that they have gotten the letter and they need to respond.
It has become very critical now because if they do not respond to the letters a few things will happen. The first thing is that Advanced Med will come to us and tell us to go ahead and recoup on this claim. We will have to take the money back. If
the provider does have the justification that they have never sent, then they will have to go through the appeals process to have the claim redetermined.
If we have made the phone call to try and encourage the provider to respond and the providers are adamant to us that they are not going to respond, then we have been instructed to turn them in to the OIG as non-compliant. We have had a few
providers respond this way. As a result it is very important that we get the providers in the mind set that it very important for them to respond.
We are able to turn providers in to the OIG for failure to provide documentation rule.
It has been difficult for us a carrier to be caught in the middle of this. Advanced Med has been sending out the letters and the providers are contacting us. The letter clearly tells them to contact Advanced Med with any questions. We have been
telling them, "Yes, you can respond by sending them the documentation."
Many providers are upset about them requesting information on small claims amounts, for example: a lab charge that was $8.00. If it is small dollar amounts, providers are telling us that it is not worth their administrative time or money to send
all of the documentation. There are many different layers here but the bottom line is that we want providers to respond and respond timely.
Not only will we have to take the money back and maybe even report them to the OIG if they are adamant about not responding, is also counting as an error against us as a carrier. That is the other side to this. Consequently, because they are not
responding it looks as though we are not processing the claims correctly. That is why we are very pro-active in getting the word out.
Sylvia Doggette, Provider Education and Training Specialist for ABCBS, suggested that the initial letters that Advanced Med sent did not suggest that they were affiliate with CMS. She explained that as educators interested in helping and protecting
the provider, we are adamant with our providers that the requesting letter should have some type of logo on it because a contractor for CMS would use that logo. Particularly if they are being asked to send documentation or the money back. This has
been corrected and should help with provider responses.
The PCOMAG suggested that we put a letter in the newsletter asking for the provider’s help. "We need your help, as a carrier for CMS" We should explain in the article that we are trying very hard to process your claims timely and this is putting us
in jeopardy.
Diane Groh, Acadian Ambulance stated that when they received their first CERT request, they did contact ABCBS as the carrier because they wanted to be sure that it was legitimate.
Suzanne Taylor stated that the real issue is that doctor’s offices have an incredible amount of work to do and they cannot afford the staff. Overhead is fifty percent or higher even if it just means that the staff person has to be able to pull the
information. The doctor is not going to be able to stay behind the staff person to ensure that they respond timely.
Pam Kanaywer of CMS explained that her understanding is that there are only two hundred requests for the state of Louisiana. In New Mexico, the two hundred requests hit them harder because of the smaller provider population.
In the conclusion, the PCOMAG felt that the CMS logo on the letters from Advanced Med would help tremendously. In addition, in the initial letter, Advanced Med should let them know that providing this information, they are not violating any HIPAA
privacy requirements. Some providers have declined to send the information until they get the patient to sign a release. This delays their response even more. We have provided this explanation in all of our articles but it is not included in the
letters to the provider from Advanced Med.
Suzanne Taylor suggested if people would just ask, "Does this have anything to do with treatment, payment or operations?" If they can say yes to any one of those three, then it is HIPAA compliant.
Pam Kanaywer of CMS will take the PCOMAG recommendations to Advanced Med. She will talk to the Medical Review people and take them through the correct process.
We will develop an article asking for the providers help with this.
A copy of the flyer that we used for our April 28 workshop was handed out. This is our old Intro to Medicare Workshop. The education staff, (Diane Weiss, Sylvia Doggette) spent a lot of time revamping this workshop. We have made it in to a full day
workshop for new providers. We need to offer it again this year. We had incredible response to the workshops we held in New Orleans. It was well received. It is very comprehensive with a wealth of information. Diane Weiss suggested that we hold on
these workshops on a regular basis.
Sylvia explained how the workshop went in New Orleans. It started at 8:30 and was supposed to end at 3:00 PM with a 30-45 minutes for lunch and five-minute breaks in the morning and afternoon. We did not complete the workshops until around 3:30 or
3:45. They both agree that while there are some areas we could scale down a little bit, they are others that should be expanded on after conducting the workshops twice. They had tremendous comments about the workshop. Some attendees asked them why we
had not been doing this all along. Diane suggests that we should provide this workshop once per quarter in different locations around the state. The experienced people come there for a refresher and to be caught up on some things that have changed
concerning the basics of Medicare.
Information provided in the workshop included how to submit a claim, how to read an EOB, how to go through the appeals process, CERT, web site navigation and a few other areas.
Kim said that we could add another one this year particularly if we can get another site to use that is free for us. FYI for PCOMAG, we are in the process of planning four for next year. With the PCOMAG’s recommendation, we would like to have two
in the North and two in the South, one per quarter.
We will include the outlines for the Fundamentals Workshop and the schedule in the back of the new provider enrollment packets so they know exactly when it is happening and when the next one is coming out. As soon as we develop next year’s
schedule, we will give it to Provider Enrollment to include.
Suzanne Taylor commented that our carrier does a much better job of educating their providers then many other carriers do in this country. She was able to name some other providers, as big as they are; they do not do nearly as good of a job of
educating the provider community.
Pam Kanaywer of CMS, thinks that in this region, we started on the right foot. We took the BPRs and the Provider Communications (PCOM) areas very seriously from the get go. Other regional offices did not.
Kim Gassie, Senior Education Coordinator, added that we have found that if we can get to the providers before the get going, you are going to save so many problems in the long run. If we get them started right, it helps. We used to be able to see
them one on one and spend time with them. We are doing that know in these bigger venues of the educational workshops. We need to let them know in the beginning, who the contact people are, what phone numbers, addresses, how to fill out the forms etc…
we do not see the bigger problems in the back end.
Sylvia added that she could remember a time when she was able to spend all of the time she needed to with a provider. This way, with the Fundamentals Workshop, we get a group of people that rather feed off each other’s questions and answers. We can
cover things like calling customer service instead of trying to call her because it may take her much longer to get to them. We get to cover much broader areas in this workshop.
Suzanne Taylor stated that her office uses the workshops as a training course, even if they are not going to work in the Medicare arena, it is still important for them to know this information.
The PCOMAG was asked to provide opinions on the letter that went out about the workshops. It is brightly colored and contains information about the workshops in April in May and the rest of the workshops through to September. Diane Weiss asked the
PCOMAG if they thought they still had this form to register for the wound care workshops or if they register for Fundamentals and threw it away. Is this a good notification? If so, how much lead-time do they need to schedule staff to attend?
Notifications are also posted on the web site. Diane suggested that add upcoming workshop verbiage to the web site update notification until the day of the workshop and then have it drop off. Kim said she would have to check with Sport to see how
it works. WBT is on every web site update. We could include verbiage about checking the web site for upcoming workshops.
The PCOMAG suggested additional verbiage on the form that we already have. We could also do a stuffer stating the specific upcoming workshops.
Suzanne Taylor added that she thought that providers need the kind of lead time that the notice sent out in December provides because they can not schedule all of their staff to attend on short notice. She feels that some providers have already
planned in advanced to send their staff.
Result: Kim will ask Sport to include something on the web site updates and she thinks that the RA stuffer is also a good idea. Additional prompts on the Customer Service and the Review lines were suggested.
Wound Care Workshops – Our next big specialty workshop driven by Medical review Data Analysis. Included in that workshop is Dermatologist, Wound Care Specialties under Podiatry, HBO Therapy.
Locations/Dates – Alexandria on July 27 through Baton Rouge on August 26.
Web Based Training- we have developed a WBT course, not to replace, but to compliment the Wound care course. This is the newest course released and is available now. We are using this in a number of ways. Our Post Pay department is also notifying
providers that they have previously contacted for Wound Care issues with a letter instructing them that we know have this course out there that they are encourage to go out there and take. This will give them a better overview of what we expect as far
as billing and how documentation should be received and other subjects like that.
Current Billing Issues – Some of the biggest we have had was the change for block 32. The PCOMAG was asked for comments. Diane Weiss asked if we found out which (Change Request) CR is the ruling CR for this. She has had some provider questions on
this.
From an education perspective, we had published an article that told providers that they have to put a complete address in block 32. The only exception is place of service (POS) 12. Based on another CR, when we tell this to providers, they go to
their vendors and their programmers and then they check with EDI for field locations and for verification. However, based on another CR (3039), EDI says they do not need that because within the processing system, the have the ability to pull it from
33, which is their physical location. Therefore, she would like to get everybody on the same page. She asked if she should tell them that it has to be completed except for an electronic submitter.
Kim confirmed that currently this is correct. If they are an electronic submitter, then they do not have to complete it.
Pam Kanaywer confirmed the CR that changed this process was for paper claims only.
There has been some EDI and CMS about this. WE now have to sets of billing instructions, one for electronic and one for paper claims. It has caused mass confusion amongst the providers. The other thing is that we are now assuming if they do not
complete block 32, we assume that the facility address is 33. We have already have found that this is incorrect because we have providers who actually did service in a different location and should have been paid under a different jurisdiction, but
were not.
Block 33 is always the Remit to address therefore, sometimes it is the physical and sometimes it is a PO box.
We have seen denials on electronic bill claims for block 32 not being completed, therefore there must be a misconception about what is actually out there.
The first CR states that if block 32 is not complete, it should be denied as unprocessable.
Pam Kanaywer reiterated that carriers are misinterpreted too. Her understanding is that the CR that requires determination in block 32 apply only to paper claims and that carriers should not have made any changes to their electronic billers.
Kim stated that during her last discussion with EDI was that they have not. If block 32 is left blank, then they are mapping whatever is in block 33 to block 32.
All we can do is educate as far as what the CR tells us. This is, you file paper it has to be completed for every POS except 12. If you are electronic, then you do not have to complete it.
Diane explained that there was one particular vendor in the New Orleans vendor in the New Orleans area. Several of them used the same software. There was going to be a charge to make that update to their software programs and they were going to be
charge to be able to have that address listed in block 32. Therefore, the vendors came back to the providers and say that EDI told them they do not have to do it. If they wanted them to do it, it would cost them money.
Therefore, Diane was telling them to make a change on how they submit their information that may result in an expense but the vendor was saying they do not have to do it if they do not want to.
That same computer system has to print their paper claims, which their paper has to have a completed block 32.
This applies only to PAPER CLAIMS. CR 3039 is what EDI uses to determine that they do not have to have it for electronic billers.
The PCOMAG suggested that the requirements be the same for both electronic and paper.
Pam Kanaywer agreed that this would make it consistent from a CMS standpoint as well because our goal is to get all providers to be electronic billers. Therefore, why not have one set of instructions for both electronic and paper.
Conclusion- *Note- Next Meeting- Thursday, September 23, 2004, 10:00 am
This meeting conducted by Louisiana Medicare Part B, Professional Services Division
Arkansas Blue Cross and Blue Shield
