Minutes for Region D DAC with CMS/NAS/CEDI

Minutes for Region D DAC with CMS/NAS/CEDI

Wednesday April 1st, 2015 9:00 AM PDT

Mariners B

Mandalay Bay Convention Center

Las Vegas, NV

Vice Chair, Gilbert Herrera opened the meeting and welcomed everyone. Introductions of the Executive Committee, DAC attendees, and the guests were completed. Gilbert reviewed our meeting protocols.

Introductions of the Contractors attending included: Dr. Whitten, Dr. Peter Gurk, Jody Whitten, and Cindy White with Noridian, Stacy McDonald, CEDI, and Elaine Hensley with the CBIC. Lisa Addison and Michael Hanna Representatives from Jurisdiction C were also in attendance.

The minutes from January 27th were reviewed. Laura McIlvaine made a motion to approve them and Bill Noyes seconded it. The minutes were approved.

Stacy McDonald with CEDI presented the CEDI Update. This is attached to the minutes.

Since there was no one present from CMS at the meeting there was not a CMS update given. Dr. Whitten apologized for their absence and said that they have been under travel restrictions, so this could be why they were not in attendance. He asked that in the future we try to have a call in line established so they can call in with their report. He will try to work with them to make this happen. Deanne Birch reminded everyone that we have sent questions to them prior to the meetings in anticipation of answers being provider for the group meetings and are still waiting for responses. Dr. Whitten apologized and said he knows they are committed to getting us the answers and perhaps the best way is to try to have a call in line established for the future.

Dr. Whitten introduced Dr. Peter Gurk the newest Contractor Medical Director for Noridian. Dr. Gurk is a Senior Medical Director, originally from Chicago and most recently with HDI. Dr. Whitten said Dr. Gurk is very willing to discuss philosophical problems and is able to provide excellent insight on problems we may be encountering. He is experienced as a Medical Director in Managed Care and is looking forward to working with Noridian and the DAC.

Dr. Gurk confirmed that CMS has put Part B audits on hold because of the contract protest. Currently they are going through the appeals process so there will be no awarding the contract until the case is settled. The only reviews that are being conducted at this time are automated reviews.

Dr. Philip Benjakul the interim Medical Director with HDI was not able to attend our meeting so no update was given. Dr. Whitten advised us to call with any issues we are seeing.

Elaine Hensley provided the CBIC Update.

The bidding window closed last Thursday. She reported they had technical difficulties so the time was extended to 8:59 pm on Thursday.

They are currently going through the process of reviewing the covered documents which were submitted to be sure everything is all inclusive. This process does not validate the information submitted; it just verifies everything was included. If they find a bid submission is incomplete a supplier will have 10 days from the notification to resubmit the required documents.

The CBIC is making enhancements to better evaluate the bid process. Suppliers will be notified when they cannot validate information on licenses and accreditations. Suppliers will have 10 days to get information to them. Suppliers will be sent an email with instructions to send proof to NSC. They cannot validate a license without this information. They feel it will be a smoother transition to just send the information to the NSC.

Suppliers can be disqualified from the bid process for other reasons than licensure or accreditation. The CBIC is hopeful that with these improvements being made that a number of the problems will be eliminated.

The announcement for Round 1 2017 should be forthcoming. Elaine has received several email questions on how/why the Government can change the competitive bidding area. Elaine explained that they recognize that a CBA may have gotten larger with time so that area needs to be included. They also looked at commuter routes so they could better include these areas which would expand the number of zip codes for an area.

Elaine said she is getting a lot of questions regarding the rollout of national competitive bidding. She has not received clarification or been updated yet, nor does she know what the CBIC involvement will be. There has not been an outside contractor appointed at this point. Sheila Roberson asked about the fee schedule for the national rollout and Elaine reported she has not been notified of this or a timeline yet.

Sheila also asked about the 2 new bundling programs and Elaine has not heard anything on this as well. She said the CBIC has submitted questions to them but there has not been a formal response at this point.

Elaine discussed assuring bonafide bids. The CBIC looks at all the bid amounts received. They do research on the internet and compare the bids submitted by all suppliers. If a question is raised that they cannot buy it or sell it for a certain amount that supplier will receive a bonafide bid letter. That supplier will need to produce invoices and information to show that they can purchase that product for the cost submitted. All bids are validated.

Sheila Roberson asked if a master list of zip codes and their applicable fees will be made available. At this point it is unsure if this could be established especially since pricing outside of Competitive Bidding goes to the MAC’s. Currently this would involve approximately 44,000 different fees. This will be a major IT issue for all suppliers.

Elaine reported that the CBIC continues to perform secret service calls to providers to find any breeches of the Competitive Bidding contract. They continue to receive complaints on the timeliness of services rendered, and providers not supplying the product until the documentation is in hand, as well as mail order complaints on the diabetic supply program. If a supplier is found at fault they will have to submit a corrective action plan.

Dr. Whitten provided the Medical Director Update from Noridian.

The ACA (Affordable Care Act) mandates the enforcement of the Face to Face requirements. CMS instructed the MAC’s to delay this enforcement for the time being. This instruction was not given to CERT so they must follow the law. CERT will continue to focus on these requirements even though NAS is not doing so at this time.

Dr. Whitten provided a keen understanding of the situation providers are in today. He explained we have the potential and capability of finding the solutions but at this point we are not there yet. He believes we need to enlist the help of other groups such as the Cystic Fibrosis Foundation, COPD, ALS, Parkinson’s groups and similar organizations who can help us show how we can better serve beneficiaries in their homes. We have the potential to do this but will need their additional help. We need to show Congress the effects their decisions have on the beneficiary. He understands we all have pride in the services we offer and want to do what is best for the patient. If we can get the proper allies on board we should be able to present the credible proof we need. One example is the changes in Complex Rehab we are seeing and the effect this will have on the patient.

CMS is swamped with appeals. The MAC’s are partially responsible for this backlog. Dr. Whitten said there is a lot of similarity on the A and B side with what we see on the DME side. Dr. Whitten suggests the DAC to look at ways we can provide statistical random sampling of claims. No one should have to go through 100’s of thousands of claims. They will welcome discussions on how this can be reduced and are continually looking at ways to reduce these volumes.

Dr. Whitten discussed the Prior Auth. program. He reminded us that he did not initially favor this program but it has been a wonderful recourse for suppliers in knowing where they stood before providing a PMD. Overall it is being reported this program is a huge success and he will be very surprised if the program will end. Because of this, Dr. Whitten is encouraging us to look ahead into portal systems such as “One Health Port” which is being used in Washington, Idaho, and Alaska and some of the commercial insurance plans. This system allows the Carrier and Provider to work together in order to provide service to a customer. Documentation is submitted, reviewed, and recorded within the portal up system to best determine the needs of the customer. By using a method such as this a provider could submit their documentation ahead of time and we would know where we stood. Using a method such as this would enable everyone to see what is in a beneficiaries health record so they can be provide the care they require. Dr. Whitten encouraged finding ways to trial this and help to make the system better.

Paula Koenig asked about adopting a program similar to Jurisdiction B’s on hospital beds and Group Support Surfaces. She explained the program is good but the turnaround time can be an issue. Dr. Whitten said that Noridian will welcome suggestions on this but encouraged us to look at ways to do this electronically. He reminded us we have to operate within the law but we can always look for ways to better our processes. He said he is seeing a greater emphasis once again on quality care throughout the Medicare program. Kim Brummett said we also want to do as much as we can upfront as we can, so we can have the turnaround in hours rather than days. She said AA Home Care will do what they can to help with Physician documentation.

Carolyn Koster asked if Dr. Whitten would elaborate further in response to his comments on Medicare’s shift in focus by looking more closely at quality care. Now that a greater emphasis is being placed on quality care with hospitals and physicians, does he envision measures similar to the PQRS (Physician Quality Reporting System) being used to measure quality care for DME providers? Dr. Whitten was unable to provide a definitive response and commented that there are many other factors that go into measuring the current PQRS from an accounting perspective that would need to be taken into consideration before a change like that would happen.

In response to a previous comment, Carolyn also asked Dr. Whitten to consider that if the decision is made to change the term “Prior Authorization” to something else, that CMS and/or the DME MACs provide the physician and hospital community a clear understanding of what the new terminology means. At present, physicians understand what a prior authorization entails and are very accustomed to providing prior authorizations in support of commercial payers and or managed care organizations. The requests are familiar to them and they understand that without them, the patient’s care is not likely to be covered. In contrast, when asked for documentation in support of a Medicare claim it is often unclear, and can vary based on product and sometimes by provider. If the plan is going to be to develop a prior auth type system (but call it something different), please ensure that the physicians and hospitals understand the new terminology and that it is clearly defined for the physicians/hospitals what document/s are required in order for the beneficiary’s care to be covered by Medicare.

Jody Whitten provided the Noridian Provider Outreach and Education Update. It is attached to the minutes.

A member asked about the possibility of ADR letters being sent electronically. Jody responded that ADRs can be retrieved via Endeavor (electronically). A member asked about the possibility of suppliers electing to receive the ADR’s only electronically through Endeavor. Jody will check on this.

***04/16/15 Update: At his time the request will STILL be sent via U.S. mail…but in the future NAS MAY give suppliers the option of only receiving through Endeavor. Jody will notify the DAC if that becomes an option. Jody will check on this.

Jody reported they are continually working with Part A and B on what information DME suppliers need. This process is ongoing and they welcome suggestions from the DAC.

Jody and Dr. Whitten encouraged members to use the reopening process whenever applicable. They said this can be used whenever we think something may have been missed by the reviewer. In these situations we should call and ask to speak to a Medical Review nurse. We should remember though that once the next level of appeals has begun we cannot go back and request a reopening. It is also important to not miss timelines.

Gilbert asked how Dr. Whitten and Jody thought the process of the combined questions was going. He wanted to be sure we did not have too many questions submitted that may be specific to Noridian. Both Dr. Whitten and Jody agreed that the process was going well, and that it was much better to have a common answer from all Jurisdictions. Jody also responded that the number of questions have not been a problem.

Kimberlie Rogers-Bowers asked for clarification on selling items to a patient without an ABN (as a non-covered item). She explained this is when someone just wants to buy something. Patient does not want to rent, and prefers to purchase out right in situations where Medicare only rents. Dr. Whitten and Jody clarified that we should use a voluntary ABN and we must be clear to the beneficiary that this item could be a potentially covered item by Medicare if we followed their payment rules. Dr. Whitten also suggested using a separate notice where this may be further clarified for them. Providers should give the beneficiary a copy as well as keep one for their records.

The question arose about situations where there may be a secondary insurance such as Medicaid that would purchase the item. Dr. Whitten said they would look into this and see if they could come up with a solution.

Kim Brummett asked for clarification when filing oxygen claims to for a PR denial. She expressed concern that there was not a process for this. We need to have a process which would allow us to receive a PR denial. Jurisdiction B previously had language addressing this, but has since been removed. Jody will check on this.

Bill Noyes presented some concerns on ICD 10 for discussion and had the following questions: Is a new DWO, DIF, and/or other medical documentation required for a beneficiary who is already on a supplier’s service, with the ICD10 transition on October 1, 2015? What information will need to be on file, will documentation be cross walked?

Final instructions on this have not been released but the requirement will remain the same as is now required and the diagnosis must be supported by the medical record. If there is a change in the patient’s condition, that information would need to be updated so it is current.

Dr. Whitten explained that the information should already be in the patient’s medical record, but if the ICD-10 transition is a one too many relationship be sure the medical record contains information to support the ICD-10. If the medical record only contains the ICD-9 code it is likely that you will have to contact the physician to obtain documentation to support the ICD-10 diagnosis.

Finally, the question was asked if ICD10 is based on date of service or date of claim submission. Jody responded that this is date of service driven.

Paula Koenig requested clarification on MM9062. This will become effective 07/15. Can a supplier transfer the title of rental items to beneficiary, at any time, or is it intended for companies who are closing their doors-and/or exiting a product category?

Jody explained this was developed for situations when a company had closed their doors. This was a way for them to still get the needed repairs or supplies needed with the equipment they received.

If we will be submitting claims in these situations and the original provider is no longer in business we would need to include this information in the HAO record and explain that the original provider was no longer in business. Medicare would also need this history of the past equipment and what happened.

Deanne Birch asked about Cert Contractor Timelines and what the required time frame for CERT to respond to an audit was? She was told that currently CERT is anywhere from 6-11 months out. Discussion followed on this and Kim Brummett reported that we did receive an answer that there currently is no time frame. Suggestions were made to discuss this with the CERT liaison. If this does not provide an acceptable solution or answer perhaps Dr. Whitten can ask their contractors.

The subject of Electronic RX’s was presented by Kimberlie Rogers-Bowers at the meeting. There are many questions surrounding this and there is not a lot of guidance. Dr. Whitten explained that CMS is looking at the many different systems that are being used and the many different processes for each of them. He explained that the MAC’s cannot answer this but their nurses are instructed to look at and document whenever something is not clear.