• 2003 Fee Schedule
• Comparative Billing Reports
• Web Based Training
• Flu Shots and Educational Efforts to Date
• HIPAA
• National Coverage Determinations (NCD) for Clinical Lab Services
• DynCorp
• Workshop Updates
• Review of Meeting Schedule for 2003
• Conclusion

Present: Merle Francis, ABCBS; Kim Gassie, ABCBS; Dr. Lynn Hickman, ABCBS; Sylvia Doggette, ABCBS; Tatsy Jeter, Louisiana Hospital Association; Shan McDaniel, Med Data Services; Charline Breaux, LMGMA; Diane Groh; Acadian Ambulance and LA Ambulance Liaison Committee and John B. Warner, LMGMA.

Merle welcomed the members to the November Provider Education and Training Advisory Group meeting at 10:00 AM.

Merle began discussions by explaining to the group that we have not received the go ahead to release the 2003 Fee Schedule due to a hold up in Congress over an anesthesia issue. The fee schedule went through the House of Representatives without delay but congress did not receive it before they adjourned for the holidays. Congress is scheduled to meet again on January 12, 2003. Medicare has not received any direction from CMS as to the delay. There is an approximate 4.4% rate reduction expected in the fee schedule. The "Dear Doc" packages are ready to go as soon as we receive the word to release them. The Ambulance Reasonable Charge Profiles will be out in February.

The Comparative Billing Reports will be in the December Newsletter. A form is available on the web site to order these. This report is an analysis to compare Physician to their same specialty peers within the state. The report provides much of the same information that Dr. Hickman provides in the Carrier Advisory Committee (CAC) meetings. We estimated that about 1000 Reports would be requested for each of our states. This report is only for Physicians.

Web-Based Training is expected to be available by the end of December or early in January. Mary Kay Sunderhaus, who was hired to be a Louisiana Educational Representative, has been hired to develop a new web-based training program.

The First Module will be on the reading of medical policies. This module should be advantageous to all providers. Mary Kay will take actual examples of denials and incorporate them into the training module. It will bring the user through a medical policy and give them an understanding of how to follow them. The reason this was chosen as the first module was because medical necessity is still the top reason for denials.

A letter will be sent to Physician’s that have high denials, inviting them to go to the web site and use the web based training module one. Progress of the providers will be tracked as part of the pilot project and results will be presented to CMS and this committee on an ongoing basis.

The second module recommended by our Provider Education and Training Process Improvement Team (PET PIT) was the use of modifiers. This was the PET PIT number one request. Kim Gassie told the PCOMAG that we are still open for suggestions for the second and third modules. Once the modules are completed each one of them will be tested in-house. Merle also suggested that the PCOMAG members test them as well, before they are released to the physicians.

If the training modules do well and we can prove to CMS that there is a value to them for the provider community and CMS, then we can incorporate the web based training into our education efforts in future years. With Mary Kay’s credentials, including her Masters in Education and her RN, she has a very well rounded basis for developing these topics. We are hoping that this will do exceptionally well.

Each module will include a pre-test and post-test. Physicians will be able to print out their score and data.

Shan McDaniel of Med Data Services would endorse the modifier idea to help eliminate some of the issues she has had with physicians using modifiers. Charlene Breaux and John Warner of the LMGMA also mentioned that they had had similar issues. The group suggests that we need to remember to tie in the ambulance modifiers with this module.

Another recommendations from the group involved taking the basic workshop material and incorporating it into a web based training course. One problem discussed among the group, which may arise from this course selection, is the difficulty in tracking the effectiveness of the training module for new providers since there is no historical billing to measure improvements against.

Other suggestions from the PCOMAG were to include:

1. How to interpret a "RA".
2. Non Physicians (NPs) and Physician’s Assistants (PA) billing procedures.

1. Dr. Hickman said that this module would be a good idea but it could not go nation wide because each state varies on the parameters for state legislation and licensing. Merle agreed and added that this may mean that we may need to do specific education on the NP and PA.

Mary Kay has created a flyer about the web based training course and it will be distributed to the Top 100 and the PCOMAG via email.

Last Year there was a big problem with providers billing for whole virus instead of split virus. This year we know there is not a whole virus. We will change the code and will bill on a split virus basis. Suggestions were solicited from the group on how to address the billing issues with the providers. The response was to include an article in the provider newsletter to remind providers to bill correctly. Louisiana still ranks low for people receiving the flu shots.

Merle asked the committee where everyone was as far as following HIPAA guidelines to become compliant. Shan McDaniel offered that Med Data is doing well and has begun testing. However, she noted that their dealings with the Mississippi contractor have lead them to believe that this CMS contractor is not as timely as the LA contractor in implementing all of the HIPAA requirements to date.

Free HIPAA software that will replace the current MED B billing software, will be available next month (December). Provider’s vendors need to be encouraged to program the 270/271 option so that their providers will have access to patient eligibility information. The availability of this eligibility information will assist providers in determining when it is appropriate to bill the Medicare part B program for services rendered. Merle noted that there continues to be a very large volume of provider inquiries for eligibility information through our Customer Service Center.

We are trying to very heavily promote the HIPAA 270/271 transaction with everyone. . Currently, the CMS instructions do not allow contractors to provide patient eligibility over the phone unless the beneficiary has given us permission to do so. We had electronic eligibility available but it was not in real time mode. The Provider Eligibility Access (PEA) option is going away because it is not going to be HIPAA compliant. The 270/271 option will be available for us to receive live requests in April. Merle advised the Committee that they should speak to their programmers about programming the 270/271 transaction for them. It will give them, in real time mode, much more information about a patient than is available now. For instance, it will give them HMO, deductible status, Medicare Secondary Payer (MSP), and the patient’s eligibility in every aspect of the Medicare Program. Merle stated that eligibility is still one of the highest reason that we get inquiries. This transaction will help to answer a majority of the eligibility questions.

It is not required that the providers have the 270/271 transaction, it is an option, but if they would like the option than they need to ask the programmers to look at the specs and tell them that they definitely want the 270/271. Merle also reminded the group that they would also need the 276 and 277 EFT Electronic Remittance Advise (ERA).

Med Data Services is already adding this option to their software according to Shan McDaniel. Shan also said that claims submissions are problematic. John Warner told the group that many physicians were already leaning on their vendors to install the 270/271 option.

The group then asked if there was some sort of checklist that Medicare could provide to physician’s that suggests what needs to be addressed in their offices to become HIPAA compliant.

The appeal time limit has been changed to one hundred and twenty days. Diane Groh suggested that Medicare conduct some additional education to the beneficiary in this area. Merle said that it is probably more of an issue for ambulance suppliers than for Physician’s, because the medical necessity of ambulance services is usually quite different from what the patients consider necessary for their use. Diane explained that when she feels that the denial is incorrect, Ken Endsley and his department do send an appeal immediately. The problem lies in when they agree with Medicare’s decision and begin billing the beneficiary. The beneficiary is not aware that there is a time limit and they wait until after time to file an appeal. The beneficiary then calls customer service and does not provide the complete story. Diane explained that she did not feel that customer service was misinforming the beneficiary, she feels that the beneficiary just does not understand the process.

Merle said that the time limit change is relatively new but the appeals process has not changed. Merle said that the information does go out on the beneficiary’s Medicare Summary Notices (MSN) and it is on the website. Merle asked the group if they thought an ARU message should be added to explain the new time limit for appeals. This message would be heard while the beneficiary was on hold. The 120-day time limit was effective October 1. The group was in favor of this recommendation.

Merle reminded the committee that there are MSNs that are sent to the beneficiaries that inform them that they do have 120 days to appeal the decision if they are not in agreement with it.

Any claim with a RA date before Oct 1, 2002 will have 6 months to appeal. Claims from September 30 or prior will still have six months. It is based on the claims processing dates rather than on the date of service.

The PCOMAG agreed that the addition of an ARU message, along with the MSN notice, was sufficient to educate on this change.

There are several significant differences on the 23 lab tests recently released in the CMS NCD. Due to budget constraints, we chose not to publish all 23 policies but instead, we have provided a link to them on the web site. This information went out in the June, October and December Newsletters. The major issues are listed below as discussed with the PCOMAG:

1. Date of Service of a specimen collection will be the date the specimen was obtained instead of the date of examination. Date of Service will not be looked at until it is mandated.
2. Extension should be requested by Monday November 25, if physicians or providers/suppliers are unable to comply with the changes in the date of service billing procedures.

Kim Gassie discussed the particulars of the diagnosis requirements for the 23 different clinical lab tests. She explained that there were three different categories of diagnosis codes that could determine whether these services were payable. The categories are listed below:

1. Meet medical necessity
2. Automatic denial due to lack of medical necessity
3. Considered, contingent on satisfaction of information provided with claims.

Kim solicited ideas for education from the PCOMAG on these policies. She explained that any current LMRP’s that were in place would be retired and replaced with the NCDs. Kim advised that the existence of these policies had been included in educational activities since the Federal Register published the policies. Kim also explained that our website would contain a link to these policies in lieu of the entire policy on our website.

The PCOMAG commented that they did not think additional education was necessary at this time.

8. DynCorp Comprehensive Error Rate Testing (CERT) Letters

Some Physicians may have already received information requests from DynCorp. DynCorp is conducting random auditing of Medicare claims to review whether or not appropriate decisions were made on the way that claims are processed. DynCorp is a company that CMS has entered into a contract with. Kim said that she has not heard of anyone that had received a reply after they have responded to request for records from Dyncorp. A phone number is provided on the letter from DynCorp.

Merle said that she believes that the reply comes to Medicare as the contractor. If DynCorp takes an issue with the way the claim is processed then we, as a contractor have the ability to appeal the decision of Dyncorp. The Dyncorp process is a contractor error rate testing. They are measuring and establishing a contractor error rate for all the Medicare contractors in the country. CMS wants to be fair to their existing contractors so the CERT program includes the process of appeal for the contractors, for any and all decisions made by DynCorp.

The letter DynCorp sends states that if you do not respond in a certain number of days it will be concluded as an overpayment. If DynCorp does not have enough information to make a determination that a claim should have been paid, then DynCorp will send a message to the Contractor, requesting the initiation of an overpayment. But, unless the Medicare contractor agrees that this was an error, they could appeal those decisions.

The provider would be notified if a decision results in a collection of the original payments.

9. DNF Initiative

In July CMS instructed Medicare contractors to add returned correspondence to the items that will cause checks to be stopped for bad address. This is part of the Do Not Forward initiative. Payments will not be sent until a change of address form is received. Also, if providers request a change and they do not have an 855 form on file, payments will be stopped until an original 855 form is returned.

Enrollment has suggested new calling hours. This is a decision that all five of our Medicare enrollment areas would like to establish. The primary reason for establishing new calling hours is to allow the enrollment staff to meet the CMS timeliness for enrollment activities. These hours are permissible by CMS and should not be objectionable to the provider community. The new hours proposed are from 9 a.m. to 3 p.m. for phone calls. We would also propose to eliminate voice mail to address the fact that with voice mail, we are getting 2 or 3 messages from the same provider. This is very time consuming and takes away staff time for completing the enrollment applications. Merle reminded the PCOMAG that appointments would continue to be an option for the providers to address any enrollment issues that were necessary. Merle solicited input from the PCOMAG on the affects of these changes on the provider’s community.

John Warner said that he feels that we would meet with resistance, if anything he feels that we need to add additional personnel to answer the phones. He has experienced difficulty getting phone calls returned he. He suggested that there be some other way to track an enrollment form without having to call in because phone calls are just not getting returned. Other members of the group agreed with John and expressed numerous concerns about getting a response from the enrollment department.

Merle then asked the group what kind of response they felt we would get if we turned off the voice mail. Diane Groh said that her office is turning off their voice mail and adding more personnel to man the phones so she did not think there would be a negative response from the providers. Shan suggested the option of receiving faxed messages. The group also agreed that fax messages might be a good idea.

Merle advised that so much information was currently received via fax, that the time and staff it would take to receive additional faxes would not be available, so this option was not viable. Sylvia Doggette suggested that there be two staff members answering the phones per day, rather than one. The group liked this suggestion and thought this to be a good idea for addressing the concerns noted for telephone issues in the provider enrollment area.

Merle advised the PCOMAG that additional staff were planned for enrollment in the FY03 budget, to address the concerns of the lack of availability. She reminded the group that there would be a training period for this staff but that two additional Specialist would be hired, increasing our staff to 5 Enrollment Specialist to handle the workload. Merle agreed to monitor the phone situation for enrollment and to update the PCOMAG at the next meeting of the results of this monitoring.

Note* Merle advised the PCOMAG that Medicare contractors can now accept a faxed signature when processing an application change request, as long as an original signature, on an original 855 form, is on file. This change from CMS will reduce the correspondence between our Enrollment staff and the providers and should be viewed as positive.

11. Workshop Updates

We are continuing to get more involved in specialty specific education. The education staff recently participated in the state Optometry Association meeting. Sylvia Doggette will have a small part in the Orthopaedic meeting on Friday. The education staff will also be participating in the Cardiology meeting as they do annually. Merle and Kim will be participating in the Geriatric meeting during the first week of December. Dr. Sun was able to get the fee waived and we will be able to participate in the Association of Family Medicine’s annual meeting by manning a booth. The booth will contain various types of educational materials to provide during the meeting. We have also planned to have representatives from our educational staff in attendance, to answer questions from the participants at the meeting.

Our office is also conducting Introduction to Medicare workshops all over the state and here at the Baton Rouge office.

Specialty Workshops for the next calendar year will begin in March will include Internal Medicine, General Surgery, Dermatology, and Psychiatric Services. These topics were chosen based on input from the PCOMAG in previous meetings and through consideration of data analysis findings.

Merle explained the new CMS focus for determining educational interventions. She explained that the most recent instructions to Medicare Contractors require medical review findings and analysis to be the driving force behind the topics chosen for provider education. Additionally, an emphasis should be placed on choosing educational topics that promote a reduction in the claims submission error rate. We will revisit everything in the spring to ensure we are covering the necessary areas and continue to seek input and guidance from the PCOMAG in workshop topic selection.

The December newsletter will include a list of all the workshops and an invitation will be sent to the physicians that are within the specialties that we will cover. This year’s budget does not provide the funding to send out invitations to all physicians for the general workshops and the basic workshops. We will monitor the attendance at these workshops to determine the effects of eliminating the special invitation to these workshops.

We are not charging for our attendance at the specialty medical society meetings that we we have solicited our participation at.. The arrangements for the facility, handouts, and any refreshments will be at the expense of the medical specialty society rather than to us. This is consistent with the CMS directive on when charging for education is appropriate. The PCOMAG was in agreement with this approach.

12. Review of Meeting Schedule for 2003

Merle advised the PCOMAG that Dr. Hickman is now the Medical Director for Oklahoma and New Mexico, as well as Louisiana. He will be sharing his time between the three areas and will not be able to attend all of our future meetings. Dr. Hickman has advised that he will attend as his schedule allows but his lack of presence will not diminish the input he will have with the PCOMAG.

The 2003 meeting schedule will be as follows:

January 30, 2003
March 20, 2003
May 29, 2003
July 31, 2003
September 2, 2003
November 20, 2003

With no further issues to discuss this meeting adjourned at 11:30 AM. The next PCOMAG meeting is scheduled for January 30, 2003 at 10:00 AM in the 3^rd floor conference room of the LA Medicare Part B Office (as usual).