Highmark Medicare Services
Provider Outreach & Education (POE) Advisory Group
Pennsylvania
Meeting Minutes
November 16, 2007
9:00 AM – 11:00 AM
Welcome and Introductions
Denise Church, Manger, Outreach and Education, welcomed the group to the POE Advisory meeting. Introductions were made of those that participated by phone and those that were present.
POE Advisory Group Guidelines and 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 POE 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.
The next meeting will be held on February 6, 2007 from 9-11 AM.
Current Quarter and Future Education Activities
Topics were requested for the upcoming ACTs and Lunch and Learn Series. Suggestions included:
- Present on Admission
- Care Assessment Pack
- Important Message for Medicare
- MAC Award
Provider Enrollment
Highmark Medicare Services, in accordance with Section 7.1.1 of Chapter 10 in the Program Integrity Manual, will request a complete CMS-855 application, if a provider/supplier requests any change to the information on their file, and they are not in the CMS Provider Enrollment Chain and Ownership System (PECOS). In the event of such a request, the provider/supplier has 60 calendar days from the date of the request to furnish the entire CMS-855 application.
If the provider/supplier fails to submit a complete application within the 60-day period, we are now required by CMS to take steps to recommend revocation of the provider’s/supplier’s billing privileges.
To avoid revocation, please submit all information requested by Highmark Medicare Services within 60 calendar days from the date of the request.
Medical Review
Inpatient SNF services-Incorrectly RUG coded—high RUGs, primarily rehab RUGs
We are having a great deal of success working with our SNF providers. We have developed relationships with individual providers under review, and corporate contacts for the large chains and this has helped us to resolve many problems. Examples include improving contact information (its very hard to work to resolve errors when our letters notifying providers of reviews to be initiated, or review results are not getting to the right people at the facilities. Another example is clarification of documentation requirements, look back periods and doc to support medical necessity.
Part B Therapy Services
For Part B therapy we are looking at high utilization—high # units/bene, units/day, units/facility averages compared with peers or “like facilities”.
The Medicare Benefit covers therapy for functional deficits when there is a reasonable expectation of functional improvement over a reasonable length of time, with goals that are achievable given the patients diagnosis and comorbid conditions. The patients have to be able to cooperate with the plan and we look for progress toward their goals for the services to be medically necessary.
Likewise, average time periods for E-stim are 10-20 minutes—not 45 min.---because there is a risk for skin breakdown. These are usually elderly patients with poor skin turgor and skin integrity—so we watch for that.
Aqua therapy for long periods-several units, several weeks is a red flag. We are not creatures who live in the water, so the therapeutic activity should transition to land and or home exercise programs—starts to look recreational if that does not occur.
CERT Update
The Centers for Medicare and Medicaid Services will be releasing the short and long versions of the November 2007 Improper Fee for Service Payments Reports. The November Report includes claims submitted in the 12 month period ending March 31, 2007.
Based on our Balanced Scorecard, claims sampled 04/2006 – 03/2007, our current paid claims error rate is around .56.
EDI Update
NPI for Primary Providers
This information is included in the November 2007 Part A EDI Xchange located on our website at: http://www.highmarkmedicareservices.com/parta/pdf/newsletters/edi/edixchange_1107.pdf
Effective January 1, 2008, your Medicare fee-for-service claims must include an NPI in the primary provider fields on the claim (i.e., the billing and pay-to provider fields). You may continue to submit NPI/legacy pairs in these fields or submit only your NPI. The secondary provider fields (i.e., attending, operating and other) may continue to include only your legacy number, if you choose. Failure to submit an NPI in the primary provider fields will result in your claim being rejected beginning January 1, 2008.
In addition, if you already bill using the NPI/legacy pair in the primary provider fields and your claims are processing correctly, now is a good time to submit a small number of claims containing only the NPI in the primary provider fields. If the claims are not rejected, we strongly encourage you to increase your NPI claim volume.
Medicare Fee-for-Service (FFS) National Provider Identifier (NPI) Final Implementation
This information is included in the November 2007 Part A EDI Xchange located on our website at: http://www.highmarkmedicareservices.com/parta/pdf/newsletters/edi/edixchange_1107.pdf
Currently, Medicare FFS allows submitters to send both the NPI and legacy PIN for inbound transactions. No later than May 23, 2008, providers should ensure that all HIPAA transactions sent to Medicare contain only valid NPI numbers (no legacy provider numbers).
Once CMS ends its NPI contingency, the legacy number will NOT be permitted on any inbound or outbound electronic transaction (there are exceptions to the 835 remittance advice - see CR5452). Once instructed to do so by CMS, Medicare contractors will begin rejecting claims, including claims submitted via Direct Data Entry (DDE), that contain legacy provider numbers for any primary provider instead of or in addition to the NPI number.
For more information, please see the MLN Matters article located at http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5728.pdf
Q. We're not using VisionShare for all providers at this time but eventually want to have all of our providers submit through VisionShare. Can we test using VisionShare with one provider now and then add remaining providers later?
A. You must contact VisionShare to see if this option is possible.
Q. Does the new PC-ACE Pro32 Version 1.87 upgrade allow the legacy number to be removed and only use the NPI?
A. No, Version 1.87 does not allow the legacy number to be removed. We are not sure when the software will be upgraded to only allow the NPI to be entered. It is possible this won't occur until CMS ends its NPI contingency, but we do not know for certain when the PC-ACE software will be upgraded to only allow the NPI.
Q. If I'm using a Clearinghouse can I also download PC-ACE Pro32 to use as a back-up to submit certain claims or if there is a problem with the Clearinghouse?
A. No, if you use a Clearinghouse then you cannot use PC-ACE Pro 32 as a claim submission back-up. You must use your Submitter ID to submit claims using PC-ACE Pro 32. If you are using a Clearinghouse then you are under the Clearinghouse's Submitter ID. You cannot use the Clearinghouse's Submitter ID to submit claims on your own and you are only allowed to have one Submitter ID. Therefore, a provider cannot be set up under a Clearinghouse's Submitter ID and also apply for a Submitter ID under their own legacy/NPI number to submit claims using PC-ACE Pro32. Providers can have only one Submitter ID to submit claims and have one Receiver ID to retrieve claim reports. Providers cannot have multiple Submitter IDs.
NOTE: Currently, enrollment for PC-ACE Pro32 is done by Provider legacy number. Starting with the next upgrade release (expected in January 2008), enrollment for PC-ACE Pro32 will be done by Submitter ID, not Provider number. More information on this change will be given as details become available.
Medicare Updates
Medicare Updates reviewed were:
- Organ Transplant Center
- FY 2008 Inpatient Prospective Payment System
- Present on Admission (POA) Indicator
- Integrated Outpatient Code Editor (I/OCE)
- Primary Insurer Applied Payment to Deductible or Coinsurance
- Bone Mass Measurement (77080)
- SNF RUG Adjustments
- Capturing Days on Which Medicare Beneficiaries are Entitled to Medicare Advantage (MA) in the Medicare/Supplemental Security Income (SSI) Fraction
Provider Contact Center
The committee was asked to comment regarding the time and topics of the Customer Contact Center Representative training. The committee had no concerns of the time of the training or suggestions regarding topics.