Highmark Medicare Services
Provider Outreach & Education (POE) Advisory Group
Meeting Minutes|
February 21, 2007
9:00 AM – 11:00 AM
- Welcome and Introductions
Kim Droboniku, Supervisor Outreach and Education, welcomed the group to the POE Advisory meeting and introduced the Highmark Medicare Services staff.
- POE Advisory Group Guidelines/Membership
The primary function of the POE Advisory Group is to assist in the creation, implementation, and review of our provider education strategies and efforts. We ask that the PCOM Advisory Group provide input and feedback on our training topics, provider education materials, and dates and locations of provider education workshops and events. The group also identifies salient provider education issues, and recommends effective means of information dissemination to all appropriate providers and their staff. The POE Advisory Group should be used as a provider education consultant resource, and not as an approval or sanctioning authority.
The focus of the group meetings should remain centered on the development and implementation of effective provider communication materials and strategies.
Future Meetings: The POE Advisory tentative meeting schedule for FY07 is May 16, 2007 and August 9, 2007.
- Current Quarter Education Activities
The following educational activities remain for this quarter: FISS Advanced, FISS Basic, Ask the Contractor Teleconference (ACT), Medicare Secondary Payer and Outpatient Rehabilitation Workshop. For dates and times, please see the schedule posted on our website. http://www.highmarkmedicareservices.com/calendar/index.html
At the November POE meeting it was suggested to have a Brown Bag teleconference on a specific topic during the lunch hour. This was first introduced in January and was very successful, our first topic was Local Coverage Determinations and we titled the series “Lunch and Learn”, we will offer this on monthly basis. Topics will be decided upon based on CERT errors, claims errors and analysis of inquiries into the contact center. Upcoming topics include- Outpatient Rehabilitation, Skilled Nursing-Glucose and RUG billing and Appeals.
The group was asked if they feel that offering CEUs for training events would provide value to providers, the group decided that they did not think that it would.
Suggestions were solicited for upcoming training and the ACT.
- No pay billing in regards to Change Request 4292 (A Lunch & Learn is being offered in March on this topic specifically, so it will not be included in the ACT)
A provider is having a problem getting no-pay bills processed correctly. The provider was not getting a lot of clear direction from the contact center, another provider had a similar problem and keyed 5 zeroes in the total and covered days field.
The provider e-mailed her biller during the ACT with this suggestion, the claims were finally able to be submitted. The contact center will take this back to educate staff.
The group was asked the best way to educate providers on reading and billing according to the LCD (appropriate modifiers, occurrence codes, etc...) Suggestions include-
- Case examples
- Teleconference to clinicians and medical directors
- Training on how to read the denials
- Comprehensive Error Rate Testing (CERT)
Erin Hotchkiss provided the CERT update. The Centers for Medicare & Medicaid Services (CMS) publicly released the short and long versions of the November 2006 Improper Medicare Fee-for-Service Payments Report. The November Report includes claims submitted in the 12 month period ending March 31, 2006. There was a slight reduction in the national paid claims error rate from the 5.2% calculated and published in the November 2005 report to the November 2006 report rate of 4.4% for all Medicare FFS programs.
The paid claims error rate was 2.5%. This represented a 31% reduction from the November 2005 PA Medicare Part A error rate of 3.6%. Nationally the error rate for all Fiscal Intermediaries is 3.1%. This shows that we have some work to do as we are slightly higher than the national average in our paid claims error rate in Maryland.
Data Analysis
HMS’ CERT Data Analysis for claims sampled 04/01/2005 – 3/31/2006 identified the following bill types, HCPCS and types of errors as driving the Paid Claims Error Rate for PA Medicare Part A:
Bill types included:
a. Outpatient Hospital (13x) –contributes 65.8% of dollars in error - No particular HCPCS driving this code
b. Inpatient SNF Part B (22x) –contributes 16.7% of dollars in error - Blood Glucose and RUG coding
c. Inpatient SNF (21x) –contributes to 10.4% of the dollars in error
Types of errors included:
a. Insufficient documentation – accounts for 36.2% of all dollars in error
b. Inpatient SNF (21x)
c. Outpatient Hospital (13x)
d. Services incorrectly coded –accounts for 46.5% of dollars in error
The top services that were incorrectly coded include Topotecan (J9350), Physical Therapy (97110), IP SNF high RUG category RVB01 and RVB02, Adenosine (J0152), Transportation of portable EKG to facility or location (SE202), EPO for non ESRD use (Q0136) and colonoscopy (45378).
Medically unnecessary service or treatment –accounts for 15.3% of dollars in error
HMS’ data analysis indicated that Blood Glucose test (82962) had high frequency (188 claim lines) of medically unnecessary services and accounted for 97% of the claim lines with errors in this error category.
Erin reminded the group of the importance of responding to medical record requests, even if they are house with a third party. If you need to change the name or address where the record requests are being sent, the website address is www.certprovider.org.
Questions regarding CERT can be sent to: questionCERT@highmark.com.
Types of errors that have a relatively high frequency and high dollars in error include:
- Insufficient documentation- 52.1%
- Services incorrectly coded- 30.7% HCPCS 97110 had a high frequency of unit change. Documentation did not support billing the number of units billed
- Medically unnecessary service or treatment-Blood Glucose monitoring
- Electronic Data Interchange (EDI)
Shelley Railing, EDI Manager announced that the existing Part A EDI Front-End Platform will be eliminated and replaced with a new, easy-to-use EDI Front-End Platform for electronic claim submission and report retrieval. Starting in July 2007, all Part A EDI billers will be required to migrate from existing EDI connection, EDI claim submission, and report retrieval methods to the new EDI Front-End Platform to continue billing Medicare electronically. Electronic billing changes will be required, so please watch for important, detailed EDI Front-End migration news and prepare for these changes to avoid negatively impacting your cash flow.
This is different from the migration that happened last year. This will stream line submission for both Part A and Part B providers.
Traci Phillips will make sure all of the Patient Financial Services Directors are informed of the upcoming changes.
The current 837 error report will not be changed.
For complete details access the following link: http://www.highmarkmedicareservices.com/parta/pdf/newsletters/edi/edixchange-0207.pdf
- Provider Contact Center – Provider Relations Research Specialist (PRRS)
Change request 4292 is creating a lot of questions in the contact center, Janine Fulginiti advised that Outreach & Education is working on a bulletin and is including this topic in the Lunch & Learn.
- Provider Enrollment
November 22, 2006 “What’s New Article” this is a great article that will inform you of enrollment issues, it provides reasons CMS requires Highmark Medicare Services to return a CMS 855. The number one reason for the return of the 855 form is that it is not signed and dated. The form can now be completed on-line and printed. The complete article can be accessed at: http://www.highmarkmedicareservices.com/bulletins/all/news-112206.html
Contractors nationally are experiencing delays in processing the CMS 855.
Currently approximately 1.7 million providers are registered for their NPI; however it is estimated that 1.6 million still need to get an NPI.
Electronic Funds Transfer (EFT) is required for all new providers.
A discussion took place on whether CMS is going to have a crosswalk similar to the UPIN directory, CMS is aware of this concern however no plans are being made to create this directory. The key difference is that the UPIN is not used for billing, but as an identifier for who rendered the service. The NPI is used for billing purposes.
Providers expressed concerns over not being able to obtain all of the referring physicians NPIs which could slow down their billing.
Concerns were also expressed over the consequences of physicians not sharing their NPIs. Health care providers must share their NPI, as it is a HIPAA requirement.
- Medicare Updates
Cathy MacKenzie provided a brief overview of the following Medicare updates was provided:
- Outpatient Therapy Cap
- Manual Exception Process
- Preventive and Screening Services
- AAA- MM5235 - Effective for services furnished on or after January 1, 2007, as a result of a referral from an Initial Preventive Physical Examination (IPPE) and subject to certain eligibility and other limitations. This provision also waives the annual Part B deductible for the AAA screening test. http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5235.pdf
- Colorectal Cancer Screening
- Prostate Specific Antigen
- No cost devices
- UB-04
- Line Item Date of Services for ESRDs 4/1/07
- Patients in a Skilled Nursing Facility that go to the Emergency Departments spanning multiple dates
- Holing Pancreas alone claims
- Local Coverage Determinations
- Open Discussion
Kim Droboniku discussed the concern we have over providers billing most drugs under the 250 revenue code and not breaking out charges if a J code exists. This is causing significant issues for medical review when they are reviewing claims, as well as creating difficulties for data analysis, as billing is very different among hospitals in Maryland. Traci Phillips will create a workgroup with the Maryland Hospital Association to work on fixing this problem. Claims were going to be returned if the dollars/units were high for the 250 revenue code, since this workgroup is being created, we will delay returning/rejecting claims.
No additional discussion occurred, as all feedback was received throughout the meeting.
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