Region D DAC
Questions for IntegriGuard and Noridian and CMS
Teleconference
February 5
th
2008
EDI/EMC
Zena Jacobi, Leader
Duane Ridenour, Assistant Leader
Executive Liaison, Troy Paz
1 We have heard that all Competitive Bidding claims would go to a common carrier regardless of where the patient lives - are there any special EDI requirements for Competitive Bidding - either in where/how the claims will be directed or what data needs to be on the claim?
NAS Response: According to the Medicare Program; Competitive Acquisition for Certain DMEPOS and Other Issues; Final Rule, pages 18006-18007:
"We also proposed to base claims jurisdiction and the payment amount on the beneficiary’s permanent residence as we have done since the early 1990s with the current DMEPOS program under § 421.210(e). Under this proposal, the DME MAC responsible for the area where the beneficiary maintains a permanent residence would process all claims submitted for items furnished to that beneficiary, whether or not the beneficiary obtained the item in that area. If the beneficiary maintained a permanent residence in a CBA and obtained an item included in the competitive bidding program for that area, Medicare would pay the supplier the single payment amount for the item determined under the competitive bidding program for that area. If the beneficiary did not maintain a permanent residence in a CBA, Medicare would pay the supplier the fee schedule amount for the area in which the beneficiary maintains a permanent residence. We believe that this proposal is consistent with our current policy, under which suppliers across the country are paid the same amount for similar products obtained by beneficiaries who maintain their permanent residence within the same geographic area."
CMS will provide billing instructions for competitive bidding in the future, including how claims should be submitted, however, claims will still be processed by all four DME MACs, based on the beneficiary’s address. Claims for competitive bidding will not be processed by a common competitive bidding carrier.
For further assistance with competitive bidding questions, please see www.dmecompetitivebid.com/cbic/cbic.nsf/(pages)/home or contact CBIC directly at 1-877-577-5331.
Carlos Reyes, Executive Committee: We are concerned that this could cause cash flow problems when suppliers are required to send both the NPI and Legacy number and issues with the NSC as they are unprepared this coming May to process these claims.
Larry Young, CMS: We will reiterate this concern to the NSC and we are sympathetc to this issue. The NSC is already aware of the concern that this could cause delays and they are committed to solving this.
2
We are now in month 24 of oxygen rental; if a beneficiary wants to switch equipment (i.e., portable) but it is not medically necessary, can the provider use an ABN for an upgrade?
NAS Response: Yes. According to the Deficit Reduction Act of 2005 Changes to Medicare Payment for Oxygen Equipment and Capped Rental Durable Medical Equipment Final Rule, page 65934:
"(2) Oxygen equipment furnished under this section may not be replaced by the supplier prior to the expiration of the 36-month rental period unless: (i) The supplier replaces an item with the same, or equivalent, make and model of equipment because the item initially furnished was lost, stolen, irreparably damaged, is being repaired, or no longer functions; (ii) A physician orders different equipment for the beneficiary. If the order is based on medical necessity, then the order must indicate why the equipment initially furnished is no longer medically necessary and the supplier must retain this order in the beneficiary’s medical record; (iii) The beneficiary chooses to obtain a newer technology item or upgraded item and signs an advanced beneficiary notice (ABN); or (iv) CMS or the carrier determines that a change in equipment is warranted.
Please refer to the article on DME upgrades for additional direction on this situation, based on whether there is a physician order or not for this upgrade.
IG Response: Question is, what type of equipment is being switched out and what type of equipment is replacing it. There are 2 parts to this issue:
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simply changing equipment - e.g., replacing an old concentrator with a new one, or changing modalities or e.g. from a concentrator to a liquid system; andIn scenario 2, if the bene wants a portable system and can qualify, it is not an upgrade. If the medical necessity for a portable system can not be met then an ABN situation
exists and the bene may be liable for payment. Again no application of any upgrade. For a change in portable equipment, scenario 1 applies.Below is a decision tree or chart that provides general answers to regarding upgrades. Based on the information presented your question pertains to a switch in equipment, to what is considered upgraded equipment, after the originally ordered equipment has been delivered to the Medicare beneficiary, without a new physician’s order. Please review an article published on the EDS, now SGS, web site regarding Upgrades. This is what was explained regarding upgrades without a physician’s order:
"The supplier may not use the GK or GL modifiers if there is no physician order for either the upgraded item or the item that otherwise meets coverage criteria. In this situation, the HCPCS code for the item that is provided must be billed with an EY modifier and the claim line will be denied.
The supplier may not use the GK or GL modifiers if there is a physician order for the
upgraded item but the supplier provides an item that meets coverage criteria. In this
situation, the HCPCS code for the item that is provided is billed but the EY modifier
should not be used. This is another exception to the general instruction that an EY
modifier is added to a code if there is no physician order for the item that is billed."
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3 If Medicare denies or recoups payment for the last month(s) of a capped rental period, does the equipment title stay with the provider? Our first thought is that the titles stays with the provider as 13 months of the rental have not occurred. It also states in the ABN guidance from CMS that "If a beneficiary is relieved of liability for an item that is denied, subject to State law, the contract for the sale or rental of the item is cancelled. If the item is resaleable or rerentable, the supplier may repossess the item for resale or rerental." If the claim is resubmitted and is then paid or a future month is paid, resulting in 13 months of rental payments, the title transfer would then occur at that point. 4 POS 16 – TEMPORARY LODGING *16 Temporary Lodging (April 1, 2008) A short-term accommodation such as a hotel, camp ground, hostel, cruise ship or resort where the patient receives care, and which is not identified by any other POS code. |
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a) Will DMEPOS suppliers be instructed to begin submitting claims with POS 16 effective April 1, 2008 if patient location applies?
NAS Response: MLN Matters 5777 has already provided this instruction. This was published on the NAS website on 11/29/07. This new POS does not change in what locations DME is paid for. It is still a benefit for use in the "home".
b) Define temporary and/or short- term (i.e. 3 months, 6 months, etc)?
NAS Response: Temporary and/or short-term was not defined by CMS but NAS interprets this definition to be a living situation that is temporary and not intended to be permanent. For example, a beneficiary moves to a hotel due to some damage to their residence from a fire, flood or other natural disaster. They plan to stay here for several months, but the long-term plan is to go back to their home. Some beneficiaries live in a campground all the time so this is their long term residence or home and POS 16 would not apply. If a place of residence is permanent and considered the patient’s "home", POS 16 may not apply.
c) POS 16 vs. POS 12. If the beneficiary is staying at a family member’s house, which code is used?
NAS Response: POS 12, as the definition of this is a location, other than a hospital or other facility, where the patient receives care in a private residence. POS 16 does not address the location of a private residence.
d) If a beneficiary stays at his/her winter home for a lengthy period but is a permanent resident at another location, what POS code is to be used when at the winter home?
NAS Response: NAS would interpret the winter home to be a POS 12, home. POS 16 does not address a private residence.
e) Please confirm that the DMEPOS benefits that apply for POS 12 also apply at the same reimbursement schedule for POS 16.
NAS Response: Yes, POS 16 will be treated the same as POS 12 for payment purposes.
f) When the location for POS 16 is different from the permanent residence location, what address is used for determining the Jurisdiction responsible for the claim and from what data source is this address obtained from?
NAS Response: The address used to determine jurisdiction is the patient’s permanent address on file in the claims processing system, which comes from the Social Security Administration. Suppliers should not report the POS 16 address on the claim unless this is the beneficiary’s permanent address on file.
g) What patient address is to be submitted on the claim when living in a location other than POS 12 would be used for?
NAS Response: Suppliers should continue to report the permanent address on file with SSA and only report the "new" temporary address if the patient has updated their address with the SSA. The POS and address are two different pieces of data and are not validated against one another. For example, if a beneficiary is in a NH but has not updated their permanent address and their permanent address is still their home, the address would be their home but the POS would the facility where they are located.
h) What other requirements will be apply to suppliers when the POS 16 is used?
NAS Response: There are no other requirements for using POS 16. We feel that this will be rarely used, as POS 12 is the most applicable POS for most situations.
No further questions
5 A supplier is experiencing denials for same/similar at the claims level and repeated denial decision at lower appeal levels. Once the appeal reaches the ALJ level, the claim is rendered payable. At what point does Noridian or any subsequent level of appeal consider that if a denied claim is seeing routine appeal success at the highest level that the claim should just be paid as a matter of course? In the supplier’s example, the supplier has the attached verbiage as part of their Patient Acknowledgement and Assignment of Benefits language. Noridian and other levels of appeal feel that this language is being incorrectly utilized as an invalid ABN. The language is not written on an ABN. It is part of the Terms and Conditions for rental or sale with the supplier.
IG Response: Same/similar denials are R&N denials. R&N denials must be addressed via an ABN, not using the mechanism described below.
Following is the example of the form
CUSTOMER:____________________________________ EQUIPMENT:__________________________
ASSIGNMENT OF BENEFITS
I___________________________________authorize and request payment of any Health Insurance benefits be made on my behalf to Supplier for any services or products furnished to me by Supplier. I authorize any holder of medical information about me to release to Supplier and its agents any information needed to determine these benefits or the benefits payable for related services. Please assign my benefits for services provided by Supplier for the period prescribed by my physician.
SAME OR SIMILAR EQUIPMENT
It has been explained to me that my Health Insurance carrier will not pay for 2 pieces of the same type of equipment at the same time. This includes but is not limited to Manual Wheelchairs, Power Wheelchairs or Power Operated Vehicles (scooters), Walkers, Hospital Beds, Commodes etc. I attest that I do not have any other equipment similar to the equipment that I am now receiving from Supplier, that is either being rented or has been purchased by Medicare or any other Insurance Carrier.
It has been explained to me that if the above statement is incorrect that I will be responsible for the purchase, rental or forfeiture of Supplier equipment and this Assignment Agreement. I also understand that any denial for Same or Similar Equipment cannot be reversed and that I am fully responsible for the entire purchase price.
BILLING PRACTICES
This notice is to inform you of Supplier policies and procedures regarding billing. As a courtesy to you, we will bill your primary and secondary insurance, provided we are given the correct and current billing information. If you do not have a secondary insurance, you will be responsible to pay for your estimated copay at the time of service. It is Supplier policy to obtain a Certificate of Medical Necessity (detailed prescription) and/or a Doctors’ Prescription for each item a customer receives. In some cases this may delay billing until the information is obtained from your physician. Once this information is received your insurance will be billed promptly. Should the Certificate of Medical Necessity or Prescription not qualify for reimbursement by my Insurance Carrier I agree to return the equipment immediately and exchange it for the equipment that may qualify or elect to keep the equipment and sign an agreement to be responsible for any difference between the qualifying equipment and the equipment which is provided to me herein. A statement will be sent to all customers monthly. This statement will reflect the amount for which you are responsible. Outstanding customer balances are subject to finance charges at 1.5% per month (18%annually). Ultimately you are responsible for payment of services provided to you by Supplier If after 90 days, Supplier has not received payment from your insurance company, you are responsible for payment in full.
I ACKNOWLEDGE AND UNDERSTAND THE ENTIRE CONTENTS OF THIS PAGE FRONT AND BACK.
_______________________________ ________________ __________________
Beneficiary Signature Date Insurance Id #
_______________________________ ______________________ __________________
Representative Relationship to Beneficiary Date
IG Response: No, ALJ determinations are not president setting. We do take appeals determinations in development of policy. Same and similar denials are R&N denials. What is presented here is a contract agreement. A&N denial requires an ABN in order for the supplier to collect payment from the beneficiary. Noridian is correct in their assessment, this is not a valid ABN.
NAS Response: NAS at an appeals level must follow the CMS guidelines to the letter of the law. This is also true for QICs at a reconsideration level. ALJs have more latitude in interpreting the law. ABNs should be obtained for same and similar denials to inform the beneficiary that they will be liable if a denial occurs. It is also very clear from CMS that the ABN form mandated by CMS, the CMS-R-131 form, must be used. The form used by the supplier in this situation does not comply with the ABN standards and is therefore not a valid ABN. Please refer to www.cms.hhs.gov/transmittals/downloads/ab02168.pdf for the complete ABN guidelines.
RESPONSE TO Q&A #5:
Janet Kirsch of NAS: If I understand correctly, your wording that the beneficiary states they do not have same or similar equipment process is being upheld at the higher level but is not being upheld at the lower level or at the NAS level.
Marshall Pollock, HME Team: Yes, and that NAS is not practically bound by those decisions and that seems incongruent to us, and that the appeals system and CMS has said this is wrong. That seems to be a waste of everyone’s time and money.
Janet, we would need to look at those decisions and then follow up.
IV/PEN
Deanne Birch, Leader
Cheryl Stokes, Assistant Leader
Executive Liaison, Troy Paz
6. Regarding the announcement posted on Vancomycin administered via an external infusion pump the IV team has three questions:
A Will we still need to obtain an ABN?
NAS Response: No, as Vancomycin is always non-covered and is always patient responsibility. We encourage suppliers to educate the beneficiary regarding this and the Notice of Exclusion from Medicare Benefits form, found at www.cms.hhs.gov/BNI/Downloads/CMS20007English.pdf, can be used for this purpose, if desired.
The NEMB form is a form developed by CMS for beneficiary education about non-covered services. This form does not need to be signed by the patient and does not hold the patient responsible for denied services, when signed, unlike the ABN form.
B Would we then bill with the GAGY modifier?
NAS Response: It is never appropriate to bill with both a GA and GY modifier on the same claim. The GA means that an ABN has been obtained, while GY states that a service/item is statutorily non-covered, which means that an ABN is not required. Please reference the article titled "Proper Use of GY, GA and GZ Modifiers" posted on the NAS website for additional information.
C If we bill with the GAGY modifier, and we send the EIP DIF for the pump, won't that result in a medical necessity denial?
NAS Response: Vancomycin will always be denied as non-covered, rather than for medical necessity.
No further questions:
Medical Supplies/Wound Care
Robert Clock, Leader
Executive Liaison, Sharon Nichelson
7. Suppliers are concerned that the LCD and Policy Article have not been revised since January 2007, and do not include the items in bold from the MLN SE0738, in particular to the remark about needing an annual prescription. This criterion was removed from the LCD in July 2005. Has the requirement changed again? If it has, what is the expected effective date of the change, and when is it expected to become part of the LCD and Policy Article?
MLN #SE0738 was published by CMS Nov 19, 2007. It indicates that blood glucose monitor /supply prescriptions should include:
That the patient has diabetes;
What kind of blood glucose monitor they need and why they need it (i.e., if they need a special monitor because of vision problems, their doctor must explain that.);
Whether they use insulin;
How often they should test their blood glucose; and
How many test strips and lancets they need for one month.
A beneficiary needing blood glucose testing equipment and/or supplies:
Can order and pick up their supplies at their pharmacy;
Can order their supplies from a medical equipment supplier, but they will need a prescription from their doctor to place their order. Their doctor cannot order it for them;
Needs a new prescription from their doctor for their lancets and test strips every 12 months.
The Glucose Monitor/Supplies LCD states:
The order for home blood glucose monitors and/or diabetic testing supplies must include all of the following elements:
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All item(s) to be dispensed;
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The specific frequency of testing;
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The treating physician's signature;
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The date of the treating physician's signature;
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A start date of the order - only required if the start date is different than the signature date.
An order that only states "as needed" will result in those items being denied as not medically necessary.
A new order must be obtained when there is a change in the testing frequency.
The ICD-9 diagnosis code describing the condition that necessitates glucose testing must be included on each claim for the monitor, accessories and supplies.
If the patient is being treated with insulin injections, the KX modifier must be added to the code for the monitor and each related supply on every claim submitted. The KX modifier must not be used for a patient who is not treated with insulin injections.
If the patient is not being treated with insulin injections, the KS modifier must be added to the code for the monitor and each related supply on every claim submitted.
NAS Response: The Bolded sections of MLN #SE0738 published by CMS on November 19, 2007 regarding a new physicians order was an error and was revised on 12/12/07 by CMS. This was published on NAS’ website on 12/27/07. The MLN Matter states the following in regards to the revision:
"Note: This article was revised on December 12, 2007, to remove a bullet point on page 3 which indicated an initial prescription needed to specify how many lancets and test strips were needed for a month and to remove a second bullet from the same page that stated a new prescription is needed every 12 months for lancets and test strips. Both of these requirements were eliminated from local policy. "
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IG Response: The LCD does not require updating. The Bolded MLN #SE0738 published by CMS Nov 19, 2007 regarding a new physicians order was an error and CMS has published a revision of the article as of December 12, 2007.
No follow up questions
O&P
Karl Lindborg, Leader
JR Brandt, Assistant Leader
Executive Liaison, Sharon Nichelson
8. The Jurisdiction D O&P "A" Team is requesting an update from Noridian and IntegriGuard regarding their reply provided July 17 th 2007 via a joint TeleConference on the two questions submitted by our team.
The "A" Team desires clarification specific to the use of addition codes on lower extremity orthopedic bracing and guidance from CMS for utilization of multiple suspension addition codes for lower extremity transtibial prostheses.
NAS / IG Responsed stating that "Answers to these questions require further consideration and discussion. It is essential you receive consistency in response across all DME PSC Jurisdictions. These have been forwarded to all DME Medical Directors for discussion in the near future and will be prioritized in due course of time."
The O & P A Team has established a small group of DAC D O & P Team member orthotists and prosthetists with extensive experience in providing and billing for lower extremity prostheses. This group will be happy to provide assistance to Dr. Pilley and the other Medical Directors if there are questions regarding the medical necessity of multiple add on codes. Please contact Karl Lindborg, O & P A Team Leader to coordinate communications.
9. The Jurisdiction D O&P "A" Team would appreciate any update on the status of the
Medicare Draft Knee Orthoses Policy.
We understand that Dr. Pilley has reviewed our comments and found most of them being addressed in a "Response to Comments" document currently under development. At the time, Dr. Pilley could not specify a date of release of this document but anticipated it would be in the near future.
Please provide an update on the status of the Draft Knee Orthosis Policy.
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IG Response: Answers to 8 and 9 above:
i. The KO Draft LCD is under review be the DMDs. The release date remains to be determined. The release of the Final KO LCD for notice will be accompanied by the "Response to Comments" document.
ii. Guidance for utilization of multiple suspension addition codes for lower extremity transtibial prostheses will has been discussed by the DME PSC Medical Directors and remains pending. Any recommendations you have regarding coverage for these addition codes will be reviewed by the Medical Directors..
We thank you for your responses and as regard question 9 and the multisuspenstion addition codes for lower extremity transtibilal prosthesis. In your reply you stated if we have any recommendations would we be willing to provide the to the medical directors would be reviewed by the Medical Directors and we have assembled a team of O&P specialists, developed and algorithm and would be willing to forward this to you. Our question is would you like us to addressed in the next round of a question and answers would you like this presented in another format.
Dr. Pilley, IntegriGuard: I think your thoughts would be very helpful and I would turn this over to Bob Szczys, but likely in this is the right forum. Right now our focus is on the transition and the HCPS updates and the the alpha- numeric workgroup. If you forward this to us then we’ll forward to the other jurisdictions and SADMERC for further review. .
10. At the MedTrade Q4 Q&A, the issue of dynamic orthotics being placed in nursing homes and being reimbursed was discussed. Dr. Pilley was asked to discuss this issue with the other Medical Directors and possibly releasing a bulletin to notify all suppliers that dynamic orthotics billed with an E code (DME capped rental items) were not reimbursable in nursing homes. Can we have an update as to whether this has been discussed and if this will be forthcoming? Can NAS investigate the reimbursement of these claims? Has NAS stopped paying for dynamic orthotics in Place of Service skilled nursing home or nursing home?
NAS Response: In regards to whether NAS allows payment for dynamic orthotics in a skilled nursing home or nursing home, the claims processing system currently does not allow POS 31 (SNF) or POS 32 (nursing home) for dynamic orthotics. The codes that were randomly checked were E1800, E1802, E1805, E1812, E1830 and E1840.
Karl Lindborg, O&P A-Team: With respect to your stopping payment to dynamic orthosis in nursing homes, we accept your answer, but wish a new policy update could be addressed. We wish you could come up with a solution due to the hundreds of thousands of dollars that are at stake here and spent on these patients.
Dr. Pilley, IntegriGuard: Understood, noted.
11. Will an ATP employed by a Supplier be able to perform the functions of an ATS for recommendations for complex rehab products (K0835 and above)?
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IG Response:
Yes
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No Questions.
Respiratory
Gemma English, Leader
Colleen McKenna Shaw, Assistant Leader
Executive Liaison, Carlos Reyes
12. The 120 minutes total sleep time noted for CPAP coverage is contradicted
in the Bipap policy that still references total recording time. Is the Bipap information incorrect, or are the rules different under RAD
Gemma English, Respiratory A-team: Thank you. On #12 is there any revision on the CPAP NCD.
Dr. Pilley, IntegriGuard: We haven’t heard definitely, but it makes sense. There will be a call with CMS on Thursday, and I’ll bring it up on the call. We have asked the coverage analysis group to take a look at the particular language. BIPAP is really separate language, separate from CPAP; it really makes sense to revise this as one is covered by the NCD and one isn’t.
13 (Q)Per the Supplier Manual chapter 3--a cmn must be sent to and completed by the treating physician. In many situations, we have patient's that are discharged from a hospital and O2 is ordered. In many of these situations this physician is NOT the patient's treating physician but a locum tenum or a ER Physician.
If we send the paperwork to the patient's treating physician they will most often return it with a note stating that they did not order this for their patient.? Are we allowed to get a CMN from the ordering physician?
If this is allowed that when the recert is due we would be expected to get the documentation from the patient's treating physician. However, if I could get clarification on this it would be most helpful.
Follow up Question: Frequently patients with ALS and other chronic respiratory diseases will use a Respiratory Assist Device with a back-up rate and are fully dependent on the equipment to breathe. Equipment failure can result in immediate life threatening consequences for the patient. Now that E0471 has been removed from the Frequent and Substantial Servicing payment category, and the patient owns the unit after 13 months, what options are available to the beneficiary for backup equipment? Under the CMS Backup Equipment rule, backup is at the supplier’s discretion when the device is under FSS, not when it is rent-to-purchase. (Follow up Question for Dr. Pilley, he was going to research…)
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The Medicare beneficiary is not restricted from purchasing backup equipment. Medicare does not provide payment for backup equipment for a Respiratory Assist Device with a back-up rate. A Respiratory Assist Device is used to "assist" the patient having difficulty in breathing to breath with less effort. Discontinuance or stoppage of the device should not cause respiratory failure because the patient can still breathe on their own.
Follow up to answer on RAD backup equipment:
Many patients who have a long term debilitating disease such as ALS may use a Respiratory Assist Device such as a Bilevel unit until their disease progresses to the point they need a trach and ventilator. If a patient is in respiratory failure but maintaining their respiratory equilibrium by using a RAD and it fails, the patient could quickly crash. Some patients choose not be put on a vent at all and will use the RAD as a comfort measure until they die. It appears that the answer below is making the assumption that the patient in question's disease has not progressed to the point where they cannot breathe on their own. It is correct that it is an ASSIST device but the question is how much is it assisting, 20%, 50%, 70%? We think this situation would then require a case by case evaluation to determine what type of back up equipment if any a patient would require. Some patients might be OK waiting for a back up to be delivered while others would require a quick response or an emergency room visit. If a patient owns their equipment, they basically have no service provider. So if their unit crashed at midnight, there would be no one to deliver a new RAD.
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IG Response: The Medicare program does not pay for backup equipment. Regardless of the payment category. Even when this Item was in the FSS category there was no additional payment for additional equipment.
Gemma English, Respiratory A-Team: Thank you. On the RAD policy, please understand our concern about patient care that this should be considered.,
NSC
Shelia Showalter, Leader
Wade Hendrickson, Assistant Leader
Executive Liaison, Carlos Reyes
13 . The delays by the NSC, in processing paperwork, are affecting Medicare payments. Now that edits are in place to compare the NPI address and the Medicare Supplier Number address claims are being rejected by the MACs. The problem could grow exponentially every time that a supplier has an address change. This is due to the fact that the NPI address is updated faster than the Medicare Supplier Number. How is the NSC going to resolve this problem before it gets out of control?
Wade Hendrickson, NSC: Asking a question about chain of command and NSCAC; we deal with Nancy Parker, Mark Majestic and Barry Bromberg. Is there anyone else who should we deal with at CMS to resolve issues?
Larry Young, CMS: Is there a problem with your questions and issues not being addressed?
Wade Hendrickson, NSC A-team: Several examples (21 supplier standards where we were told no new supplier standards were not going to be issued, etc…) they have used us for feedback, when and where necessary but have not used us to give input when we could have been useful to them.
Larry Young, CMS: Jim Bossenmeyer in the office of financial management is who the NSC Project officer, Barry Bromberg, reports to. He would be the contact.
There are no questions at this time.
DAC D conference call with carriers
31 July, 2008
Attendees listed at bottom.
Roll call – Barb Stockert introduced the panel including the executive committee, members in attendance from Noridian Administrative Services (NAS) and others. Barb reminded the attendees of the meeting protocol, to please place phones on mute and not to use a cell phone for this call and not to use speakerphone She also reiterated the need for only members of the DAC Executive committee and A-team leaders to speak with the Carriers. Joe McKnight called roll on attendance from each State, Members of the executive committee, A-team leaders and assistants, attendees from NAS, CMS, and CEDI contractors.
Meeting minutes – The minutes from May 6
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in Long Beach were reviewed and following a motion to accept from Carlos Reyes and a second from Troy Paz, these were unanimously accepted and stand approved.
CMS update – Larry Young: NAS CMN issue: Larry discussed issues brought forth from Noridian regarding questions about the oxygen policy and CMNs requesting further direction from NAS. Currently, Larry is awaiting an answer from Joel Kaiser on this issue. The answer at present is that these policies are still under development. Delay in competitive bidding: Larry noted the competitive bid is delayed for 18 months. Some of these claims have been released by the DME MACs for payment based on the fee schedules that existed on June 30
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prior to the CBIC implementation. Larry hopes to have this process cleaned up by September just as though the competitive bidding process never occurred.
CEDI Update - Stacy McDonald: Barb welcomed Stacy to the call and noted appreciation for her participation and her willingness to take the Q&As. The CEDI contractor will attend the DAC meetings and answer our questions. Stacy appreciated the invitation and the opportunity to get information out to the supplier community.
Enrollment Processing: Stacy stated that CEDI is currently processing enrollments from June 20
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and bringing in additional resources (people) process the backlog to get this to within 10 days of current. With this addition of manpower, suppliers should start seeing things processed faster.
Help Desk Call Volume: CEDI helpdesk is still seeing a high volume of calls to the help desk. Stacy stated that CEDI began by using dispatcher to transfer calls to more experienced technicians but it was decided this was not the best practice so they are training those dispatchers to handle calls from first call resolution. If they cannot be handled at the first call resolution level, the call is routed to a 2
nd
level supervisor for support. The people who are taking the calls at CEDI are contractors with a good deal of knowledge and within one week of training are usually able to help. Front End Reports: Stacy reiterated the need to have suppliers download their front end reports as there are number of claims rejected on the front end. Many of the claims that suppliers are having problems with at the DMEMAC level have been rejected at the front end report.
Website: There is a good deal of information on our website which is:
Other miscellaneous invitations for fall events have been received.
Workshops Held
Respiratory Assist Device
Glucose Monitor and Testing Supplies
Hospital Beds
CMS-1500 Workshop-focused on NPI and common claim errors
Manual Wheelchair Bases
Upcoming Workshops (to be scheduled):
Wheelchair Options and Accessories (CERT Focus)
Manual Wheelchair Bases (additional sessions and CERT focus)
Ask the Contractor Teleconferences
Held quarterly for large suppliers and small suppliers in 2008-schedule for entire year on website in training section
Next small supplier ACT is August 13 at 3 pm CT
September 11 is next quarterly ACT-also at 3 pm CT
ACT on competitive bidding had very low attendance-minutes available on web site.
POE Advisory Group
Latest meeting held on June 12, focused on web site and discussion about accreditation and the fact that some suppliers have not heard this message yet-have shared this concern with CMS also
Next meeting is September 18
Working on obtaining more active members and goal of two members from each state-recruitment efforts are working.
Supplier Manual
Rewrite project is still in process-PDF versions of Chapter 8, EDI, Chapter 10, Indian Health Services and Acronyms, were just posted to web site-other chapters are in progress.
Online Learning Center
We launched this on February 2 and currently 9 lessons are available under the Medicare and DME Fundamentals course.
Lessons added since last DAC meeting are: CERT, Claim Submission, DME Fundamentals and Documentation for DMEPOS
Topics under development are: Fraud and Abuse and EDI (includes ERA, EFT, MREP)
The first course for DME Coverage and Specialties course will be Refractive Lenses, which is currently being reviewed by the POE AG members. This should be launched very soon, with glucose monitors, therapeutic shoes and hospital beds next in line. These are areas of high CERT error rates.
Website Updates
Combined Ask the Contractor Teleconference pages into one page.
Revamped competitive bid web page to focus on most important information-have not removed any information at this time but have added a box about the delay
Promotion of IVR Same and Similar and Payment Floor information, along with posting IVR quick reference chart and updated detailed instructions
Updated website for CEDI
Redesigned web home page to focus on most common topics under each section and most commonly used forms
Promoting web site satisfaction survey to get more participants and feedback on website
We encourage you to take the web site survey to provide feedback as each comment is reviewed and we want to know if you like the changes. You can take the survey every 30 days.
Resource and Informational CD
All departments at NAS, from our pre-process team (mail) to our appeals team collaborated on creating a CD that was mailed to each supplier using the payee address in the middle of June. This CD contains information about each team at NAS and how we assist suppliers, along with helpful reminders on submitting information to NAS, contacts, and much more. Suppliers can provide feedback on this CD and suggestions for future CDs through the end of August by taking an on-line survey or faxing us a survey. If your office did not receive a CD, check with staff at your payee address location or call our Contact Center to have one mailed to you.
IVR Updates
New same and similar functionality launched around May 16. Payment floor information was added on June 5. The response to these additions has been great and we have received other great suggestions on improvements for CMN and DIF logic for same and similar inquiries.
Medical Review
Medical review functions are going well. NAS has started reviewing claims. We continue to receive ADMCs and are educating on what suppliers can do to make this process go smoother and to remind suppliers of the correct ADMC submission process so that less requests are rejected for lack of information. We are also diligently working on lowering the CERT error rates by calling suppliers who have not submitted documentation and providing education on various CERT topics.
Pricing, Data Analysis and Coding Contract
NAS, as the PDAC contractor, will perform the same functions that SADMERC currently does effective August 18, 2008. Our PDAC web site,
www.dmepdac.com
, will be launched next week, but please continue to reference the SADMERC Web site for transition updates and information. Many features, such as DMECS, and product reviews will be similar to what is currently available through SADMERC.
NPI-May 23
We survived the implementation of NPI only on May 23! This went very well with a slight increase in NPI calls right after May 23, but few calls now. Based on EDI edits from June, there are still quite a few claims rejecting for NPI editing, those that still have a UPIN or other legacy identifiers. We will review July edit rejections and educate more on this topic if the numbers are still high.
Accreditation Deadlines
We are awaiting more details on the recent passed legislation and what changes regarding accreditation. CMS has clarified that accreditation by September 30, 2009 is still a requirement and was not changed by the delay in the competitive bid program.
Competitive Bidding Delay
Due to the delay of the DMEPOS Competitive Bidding Program, in the 10 areas where competitive bidding was initiated, Medicare will pay for DMEPOS items, retroactive to June 30, 2008, using the standard DMEPOS fee schedule amounts. CMS will begin processing all incoming claims under standard FFS rules, no later than July 28, 2008. Any held claims will be processed no later than August 4, 2008.
To the extent possible, CMS will also automatically reprocess claims that were paid under the Competitive Bidding Program and those claims denied solely due to competitive bidding program rules. In some instances, suppliers will need to alert the contractor to claims that should be adjusted.
Reminders:
New ABN form must be used by September 1, 2008.
The revised CMS 855S can continue to be used through September, 2008, rather than June 30, 2008.
Our Refunds to Medicare Form was recently revised to allow for an immediate offset request and to indicate that the refund was due to an item being returned. Please use the new version of this form.
The Inquiry/Redetermination form is now available as a fillable and savable form. You can now save this form with your supplier specific information.
Questions for Janet:
Regarding the Same and Similar and use of the IVR, everyone noted that they liked the system and that people wished all the regions had similar systems. Sharon Nichelson asked if we would ever have additional access to the common working file. Janet Kirsch responded that this would be a decision for CMS.
Q&A
Next scheduled Meeting: Our DAC meeting is scheduled for Atlanta on the 28
th
at 9:00 AM and we will be having the DAC only meeting the night before at 5:00 PM local time. The team decided to review this and reconsider 7:00 PM since some people may not be able to make flights in that evening. The DAC Office will send out a notice regarding this.
Motion to adjourn : Troy Paz motioned to adjourn and Sharon Nichelson seconded and the motion carried.
Respectfully submitted:
Robert J. McKnight
Administrative Manager - DAC D
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Attendees: |
F Name |
Affiliatiation |
Confirmation |
Attended |
|
Young |
Larry |
CMS |
Yes |
Yes |
|
|
|
|
|
|
|
Szczys |
Robert |
NAS |
Yes |
Yes |
|
Strafford |
Jacquie |
NAS |
Yes |
|
|
Meyer |
Linda |
NAS |
Yes |
|
|
Schutt |
Tracy |
NAS |
Yes |
Yes |
|
Eberle |
Colleen |
NAS |
No |
Yes |
|
Jody |
Whitten |
NAS |
Yes |
Yes |
|
Kirsch |
Janet |
NAS |
Yes |
Yes |
|
Hallett |
Amy |
NAS |
Yes |
Yes |
|
Sorge |
Peggy |
NAS |
Yes |
Yes |
|
|
|
|
|
|
|
MacDonald |
Stacy |
CEDI |
Yes |
Yes |
|
|
|
|
|
|
|
Stockert |
Barb |
EC |
Yes |
Yes |
|
Nichelsen |
Sharon |
EC |
Yes |
Yes |
|
Paz |
Troy |
EC |
Yes |
Yes |
|
Reyes |
Carlos |
EC |
Yes |
Yes |
|
Kenny |
John |
EC |
Yes |
Yes |
|
McKnight |
Joe |
EC |
Yes |
Yes |
|
|
|
|
|
|
|
Rogers-Bowers |
Kimberly |
Alaska |
Yes |
Yes |
|
Gowen |
Emily |
Arizona |
Yes |
|
|
McIlvane |
Laura |
California |
Yes |
Yes |