8/3/2023 Part A and FQHC POE Advisory Group Meeting

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Meeting Minutes

Meeting Time: 10:30 a.m. ET

Member Attendees: Mary Altieri, Kim Bischel, Terry Boyd-Gamson, Kafi Cook, RaeAnn Couture, Chelsie Higgins, Sam Hollis, Cindy Kennedy, Vera Loftin, Sara Luther, Maureen McCarthy, Larisa Orlando, Louise Reist, Nancy Richman, Anna Santoro and Joanne Schade-Boyce

National Government Services Associates: Mary Armstrong, Connie Arszman, Olatokunbo Awodele, Laura Brown, Adela Deal, Cathy Delli Carpini, Michael Dorris, Phillip Harpenau, Christine Janiszcak, Casey Jones, Nathan Kennedy, Laura Kiker, Linda Klug, Kathy Mersch, Christine Obergfell, Cheryl Papalia, Auburn Puckett, Jean Roberts, Brittany Small, Linda Solis, Kristin Sparks, Susan Stafford, John Stoll, Michelle Vannatter-Johnson, Jan Wood and Christine Warshel

Agenda

1. Welcome/Introductions/Approval of Minutes from Previous Meeting
2. Updates
3. Review of Educational Material
4. POE AG Members Suggestions for Education and Open Forum
5. Upcoming Events and Additional Information
6. 2023 POE AG Meeting Schedule

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I. Welcome/Introductions/Approval of Minutes from Previous Meeting

Christine Janiszcak and Jean Roberts, POE Consultants, NGS

Christine welcomed everyone to the meeting. She explained the meeting is the first of the J6 Part A & FQHC POE AG members and the JK Part A POE AG members and we will continue to meet as a combined group. Christine reviewed the agenda. She asked attendees who did not register for the meeting to email their attendance to her and Jean. She indicated she sends an email to members to let them know when we post the meeting minutes to our website (by the 30th business day after the meeting) and asked the members to review the minutes then and email her and Jean any changes or questions. She asked for and received approval of the April minutes.

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II. Updates

Michelle Vannatter-Johnson BSN, RN, Clinical Review Nurse Lead, Clinical Operations, NGS

Michelle reviewed the handout “JK Part A & FQHC POE AG Meeting - Prior Authorization, Hospital Outpatient Department 3rd Quarter Updates and Reminders 2023” and provided the following information:

• On slide 2, regarding new facet joint PA requests, the data shows we received 1,525 PA requests from J6 providers and 2,356 PA requests from JK providers. For J6, there are 34 new providers and for JK, there are 27 new providers. For J6 providers, 49% of cases were affirmed, 37% non-affirmed, 10% were rejected and 4% were duplicates. For JK providers, 42% of cases were affirmed, 38% were non-affirmed, 13% were rejected and 7% were duplicates.
• On slide 3, regarding new facet joint PA requests, non-affirmed reasons include:
  • Missing the support indicating the beneficiary is experiencing moderate to severe chronic neck or low back pain that is predominately axial.
  • Missing the support indicating the beneficiary’s chronic neck or low back pain is predominantly axial and causes a functional deficit measured on a pain or disability scale.
  • Missing a reassessment after each diagnostic procedure using the same pain or disability scale.
  • Missing the support indicating radiculopathy or neurogenic claudication, if present, was treated prior to the facet joint procedures.
  • For subsequent or confirmatory diagnostic procedures, missing the support indicating at least 80% of consistent pain was relieved after the first diagnostic injection.
• On slide 4, regarding PA request rejections and duplicates for all services since 6/1/2023, for J6 cases, there were 253 (8%) rejections, 139 (5%) duplicates of 3,054 cases received. And, for JK cases, there were 481 (10%) rejections, 607 (13%) duplicates of 4,730 cases received.
• On slide 5, regarding rejections, the most common errors were:
  • Missing or invalid TOB code
  • Missing paired botulinum procedure code
  • Invalid Part A PTAN/NPI combinations
  • ASC submissions
  • Unsubstantiated expedited requests
  • HCPCS codes that do not require PA
• On slide 6, there are 40 exempt providers in J6 and 37 in JK. Those that did not qualify for ADR included 19 in J6 and 22 in JK. ADR providers include 21 from J6 and 15 from JK.
• On slide 7, there are exemption cycle reminders:
  • Each exempt provider will receive requests for ten (10) post-payment claims that include PA services billed since 1/1/2023.
  • Providers have 45 days to respond to ADR requests.
  • NGS has 45 days to render a decision on each claim.
  • Non-responses to ADR requests will automatically deny on day 46.
  • Results will be issued by 11/2/2023.
  • Exemption status inquiry tool will be updated by 12/10/2023 (add link).
• On slide 8, there are follow up email addresses:
  • NGSJKPriorAuthorization@elevancehealth.com
  • NGSJ6PriorAuthorization@elevancehealth.com

Michelle asked if any members had questions. One member asked if she would receive a copy of the presentation. Jean reminded her all members received an email a few days before the meeting with a link to all educational materials including this presentation.

Medical Review and Case Management Team Updates

Cheryl Papalia, Clinical Review Nurse Senior, Case Management Team, NGS

• Cheryl reviewed the handout “Medical Review & Case Management Team Update – 8/3/2023” and provided the following information:
• On slide 1, regarding Medical Review and Targeted Probe and Educate, be aware we have made key improvements to the MR and TPE areas on our website, including the return of Global Finding Reports and a re-vamped TPE Manual! Please review the following article for a successful TPE review: Best Practices for a Successful Targeted Probe and Educate Review. Please review the CMS initiative for Skilled Nursing Facilities (SNFs): Skilled Nursing Facility 5-Claim Probe and Educate Review | CMS. For guidance that will affect reporting requirements associated with the SNF QRP that will go into effect on 10/1/2023, refer to CMS.gov Skilled Nursing Facility (SNF) Quality Reporting Program (QRP) Training. Global Finding Reports highlight the most common denials for each edit and provide resources to assist providers in avoiding those denials and in remaining in compliance. Our website updates were completed with provider feedback and question trends in mind. With regard to other changes, we’ve updated/redone the TPE Manual, the MR and TPE homepages, corresponding articles and the KX modifier-related articles.
• On slide 2, on Appealing vs. Post-Probe Education, be aware:
  • The appeals process did not change with the implementation of TPE.
  • Education sessions are not a forum for appeals. Prior to an education session, review your denial rationales in NGSConnex or FISS.
  • If your Medical Review denied claim is overturned on higher levels of appeal, your error rate is not re-calculated, and you are still required to attend one on one education virtually or in person. If you are not successful after completing round 3 of TPE, CMS may consider overturned claims when determining additional action.
• On slide 3, we are making improvements to enable two-way communication through NGSConnex, and results letters will be available through NGSConnex. Refer to:
  • Enrolling in NGSConnex 2023

Cheryl asked if anyone had a question and she received none.

Part A CERT & Provider Enrollment (PE) Updates

Laura Brown, POE Consultant, NGS

Laura reviewed the CERT and PE handout and provided the following information:

CERT

• On slide 2 is the J6 CERT data. The chart on the slide indicates the final internal unofficial error rates as of 7/14/2023 for J6, which includes claims received from 7/1/2021 to 6/30/2022. The CMS goal is 7.36% for this reporting period. This data is confidential to the meeting.
• On slide 3, using the November 2023 data so far, we provided the number of claims in each error category. So far, 16% of claims reviewed by CERT were found to be in error.
• On slide 4 is the JK CERT data. For J6 and JK, CERT has completed the review of all claims. The error rate should decrease before the reporting period ends. One way is for providers to appeal the error if they are able. The Part A NGS CERT team may contact the provider.
• On slide 5. using the November 2023 data so far, we provide the number of claims in each error category. So far, 16% of claims reviewed by CERT were found to be in error.
• On slide 6 are the available CERT resources you can share with the provider community:
  • C3HUB is a website for providers, to assist in responding to the CERT ADRs. The website provides the submission methods that can be used to submit the documentation, provides a list of documentation you should submit according to the service type or provider type and it provides a search tool so providers can verify if the documents were received. If providers have questions about the details of the error, how to appeal or what documentation is needed, they can call the MAC. The search tool identifies the MAC’s CERT contact person and phone number.
  • On our website, we have CERT Alerts, articles to identify why the service was in error and how to prevent the error. Our website also has CERT tools and lists of required documents that should be submitted to CERT on certain services or provider types.
  • The CERT Task force consists of CMS, CERT contactor and Part A & Part B MACs. We met and created articles to post nationwide to help prevent CERT errors.
  • Providers can use the CID in the CERT Denial Finder to find out details of the error and the Medicare policy that was used to determine the error. Once they review the details they can determine if they will appeal or not.

Laura asked the members to continue to review the material on our website and forward any suggestions and/or comments to Christine and Jean to improve our CERT page.

One member questioned whether CERT communicates with the provider when there is missing information before a decision is made? Laura responded that CERT is a different contractor so she cannot be certain of all of their efforts; however, she is aware that CERT may contact the provider, by sending a second request for documentation. CERT does contact providers via phone and mail to obtain documentation. If you are aware that you have an error, you can check the tool on the C3HUB website, locate the name of person handling your claims at NGS and contact that person.

Provider Enrollment

Laura then provided the PE updates:

• On slide 2, PECOS 2.0 will be coming soon in the fall.
• On slide 3, we sent email notification about ownership having to be consistent between multiple enrollments with the same Tax ID. To prevent development on provider enrollment applications, providers should get PECOS access, learn how to use the Revalidation List tool and participate in Medicare Blasts such as the recent one on the different types of provider enrollment forms. The slide contains the following resources:
  • Email (4/11/2023): Provider Enrollment: Reminder: Maintaining Ownership Consistency of Multiple Medicare Enrollments with same Tax Identification Number
  • Email (4/18/2023) Provider Enrollment: NGSMedicare.com Website Resources to Help Reduce Development on CMS-855A Application
  • Email (5/9/2023): Get PECOS Access to Maintain Medicare Provider Enrollment Records
  • YouTube Video “How to Search Medicare Revalidation List Tool for Revalidation Due Date”
  • Medicare Blast - Medicare Enrollment (7/12/23)

There were no further questions for Laura.

POE Jurisdiction Affairs Update

Michael Dorris, Jurisdiction Affairs Lead, NGS

Michael provided a review of the following topics which he learned about during a recent conference he attended in Washington, D.C. of various Medicare advocates and provider groups:

• Because Medicare receives a large volume of returned beneficiary mail, please ask your Medicare patients who come to your facility if their address has changed. If so, advise them to submit the change to the Social Security Administration by going to www.SSA.gov and completing a change of address or by contacting the SSA via the 800 number.
• There is a lot of news about fraud, abuse, and data breeches that impacts health plans and Medicare. Medicare beneficiaries who are impacted can obtain a new Medicare card. CMS may issue new cards due to large-scale breeches. Otherwise, if a Medicare beneficiary has had their number compromised, he/she can contact 1-800-Medicare to obtain a new Medicare card. Michael will have information send to members that explains what providers should do when a beneficiary’s Medicare number, MBI, changes. Note: Our NGSConnex portal includes a MBI look-up tool you can use if there is an issue with a MBI.
• Sometimes a Medicare beneficiary in a hospital is referred for further care and there may be a need to locate a physician, clinician, home health agency, DME supplier etc. Michael will have an additional document sent to all members that has great links on Medicare.gov to find ordering/referring physicians who accept Medicare.
• There is a Qualified Medicare Beneficiary program. People enrolled in this program have Medicare and Medicaid. QMB helps with Medicare premiums and cost-sharing amounts (deductible and coinsurance). NGSConnex provides QMB information including the effective and termination dates and the state. It is estimated that 4.7 million people may be eligible for a Medicare savings program like QMB but are not enrolled in one. If you have patients struggling to pay deductibles and coinsurance amounts, encourage them to contact 1-800-Medicare or the State Health Insurance Assistance Program. SHIP is a free, unbiased, service that assists beneficiaries with enrollment.
• There is a lot of information about various Medicare plans and Medicare Open Enrollment is from 10/15/2023 through 12/7/2023. If your patients need help determining what plan is best for them, advise them to contact 1-800-Medicare or the SHIP for free and unbiased assistance. If the beneficiary does not make a coverage choice, that is essentially a choice.
• We are working on a special fraud project called the Senior Medicare Patrol program with the states of Illinois, New York, Maine, Rhode Island, and Wisconsin. Once this program is operational, it will give providers in these states an opportunity to work with it. When beneficiaries look at their bills and Medicare statements, they are often confused. They believe they did not receive the services and file a complaint with you. However, data shows most times the beneficiaries did receive the services. Thus, the SMP is being created to allow you refer the beneficiary to a third party to handle the beneficiary complaints. Providers will also be able to contact the SMP program to explain the beneficiary did receive the services so the SMP staff can reinforce this with the beneficiaries. We will provide additional information once the program is launched and hope it will reduce provider and beneficiary burden. One member questioned whether the provider’s billing department or customer service staff would be referring patients to the SMP program. Michael responded that either department would be appropriate as well as beneficiaries. The member also asked if, when the provider does receive a complaint, NGS would get the beneficiary in touch with this team? Michael explained the complaints will come in many different ways, and we are trying to reduce those unnecessary complaints to 1-800-Medicare since those are usually cases of misunderstandings. Michael also noted that they are planning to create a script for our providers to use as well as scripting for SMP program staff. He said we are hoping this non-biased group can assure beneficiaries when there is no fraud and there is no need to file a complaint. The member asked how will the agency verify that the beneficiary’s visit was not fraud and asked if the SMP will provide scripting or language for providers to use for referring beneficiaries to the program? Michael noted that the staff are required to complete robust training to handle such situations and there would be scripts available for providers they will be able to use upon receipt of a beneficiary complaint. Michael asked members to send suggestions to Jean and Christine on how they believe the program should look. The member then asked how the SMP program will verify that complaints are not fraud. Michael explained each person at the agency will receive at least 40 hours of training. They will then work with the patient, look at the statements/additional information and contact the MACs as necessary.

Jean Roberts sent Michael's updates to POE AG members via email on 8/15/2023.

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III. Review of Educational Materials

Jean Roberts, POE Consultant, NGS

Jean provided the following information:

• We issued an article on an issue with the CWF concerning the first date of dialysis, Update: End Stage Renal Disease Claim Adjustments Needed Due to CWF Error in Date of First Dialysis. Be aware that once the issue is corrected, we will update the article again and provide any necessary instructions for claims correction.
• We posted a message, Claims Department Requires Additional Information for Processing Certain Claims, explaining we reissued two articles and added a third to help our providers understand what to do when our Claims Department requires additional information to process certain claims. We wanted to make providers aware that when our Claims Department (not Medical Review) needs additional information to process a claim, they will return the claim to you and notate in Remarks the information that they need. The provider would then add the information to Remarks and return the claim for processing. Be aware you can use the Remarks section of the claim to submit the information needed on an original claim rather than wait for the information to be requested. The first two articles are updates to previously published articles and provide additional information based on information the Claims nurses need to process impacted claims. The third article is new and in response to providers struggling to provide the correct information for claims with external VAD. These articles are intended to help guide you toward submitting claims with sufficient information to allow us to price and process your claims. Review the articles so you can prepare claims accurately and handle claims department requests for additional information.
  • Part A Claims for High Cost Items and Certain Drugs Requiring Additional Information
  • Claims for Drugs Without a Product-Specific Code Assigned
  • Manual Review of Claims for Replacement of Supplies and Accessories used with External VAD (new article)
• We posted an article on a topic on which we have been conducting webinars for our providers. Please review the article and attend one of our webinars if you have not. The article is URGENT: Billing Reminders for OPPS Providers with Multiple Service Locations. Urgent: Provider Compliance Required Effective 8/1/2023. This Update Impacts Payment for OPPS Facilities. Note: The Revised article SE19007 includes a permanent implementation notice. All of the remaining webinars are posted on our Events calendar along with webinars on PE. To avoid reason code 34977, 34978 and additional reason codes, bill us properly by ensuring the service facility address on your claim matches what is in the PECOS and the appropriate modifier on your claim (PN, PO or ER). Also read Attention All OPPS Providers: Provider-Based Department Edits Being Implemented on/after 8/1/2023.

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IV. POE AG Members Suggestions for Education and Open Forum

Jean Roberts, POE Consultant, NGS

Jean reviewed the “J6 Part A POE AG Education Tracker” handout as well as education suggested by JK Part A members. Jean explained the following information:

• The topics members suggested for education are in the tracker. When we receive a suggestion from a member, we place it in the pending section. Over time, we may move the suggestions around. By placing the suggested topics in the pending section of the tracker, we can then research the topic. We may need more information from the member. The suggested topic remains in the pending section while we research or while you research, if we had asked you to do so. Once we’ve determined our plan to address the suggested topic, we move the topic to the processing section of the tracker. Sometimes, we just provide educational resources we created or had available. At that point, we ask our members to review the resource(s) to determine if they address the topic. If we receive no feedback, we move the topic to completed. This does not mean we remove the topic from the tracker entirely. Suggestions flow from section to section depending on the situation. The tracker is fluid. We will discuss this tracker at each meeting. As you review the tracker, you will see a member suggested clinical trial billing and we are asking the member to review the website article to determine if it is sufficient. On the tracker, you will see a suggestion for observation education, and we advised the member that, in May of 2022, we conducted a session on the MOON. Since more than a year has passed, it may be time to educate on observation again, but we want to know from the member if he/she feels the session provided targets the specific suggestion and if not, to provide more detail on what is needed. On the tracker, you will see a member suggested the topic of billing noncovered services, and we did review this topic in the October 2022 Virtual Conference, so we need the member to review that information and advise us if it is sufficient. On the tracker, you will see a member suggested the topic of claims editing with reason code W7092 and we are asking the member to review the resources we identified to determine if they address the suggestion. A few members suggested similar topics of billing of hospital claims when an outlier is reached, calculating the outlier threshold and billing when hospital benefit days exhaust. On the tracker, you will see we educated on a variety of inpatient acute care hospital topics in our May of 2022 VC. The members should review the tracker and let us know if the resources were sufficient. With regard to the suggestion for billing OP behavioral health including intensive OP and PHP services, we will move this topic to the pending section of the tracker. CMS is planning on offering intensive OP services in January 2024 so we anticipate we will be educating on this, but it depends on CMS. We may conduct a session on PHP in our Fall VC.

Christine added that she will review her requests for education on device credits to determine what education we have and what additional information we may need.

Jean asked for comments on the tracker. One member commented that some links are not working. Jean asked the member to email us if there is a specific item she is unable to link to. Jean asked members to email Christine and her with any further input on the tracker.

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V. Upcoming Events and Additional Information

Christine Janiszcak, POE Consultant, NGS

Jean and Christine reviewed upcoming NGS educational events and asked members to visit the Events tab on our website to review the most current events. Jean reviewed the resources outlined in the agenda and asked members to promote the use of self-service tools.

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VI. 2023 Meeting Schedule

Jean Roberts, POE Consultant, NGS

Jean thanked everyone for attending and mentioned the next meeting will be held on 12/7/2023.

Meeting Adjourned

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Posted 9/7/2023