Region D DAC Combined Meeting Minutes

Region D DAC Combined Meeting Minutes

Committee: Region D DAC Combined Quarterly Meeting / Time called to order:
Date: 03.01.16 / Time adjourned:
Members Present: Attendee List Attached to the Minutes / Location: In Person Mandalay Bay Convention Center Las Vegas, NV.
Contractor Attendees:
NHS: Dr. Peter Gurk, Cindy White,Tia Hastings-Rowe, Dr. Barbara O’Neal (telephone)
CEDI: Stacy McDonald and Sally Hopkins
CBIC:Elaine Hensley
CMS: Laurie Tan(telephone)
C2C: Daniel Roach
Jurisd. C: Michael Hanna / Chairperson: Gilbert Herrera
Recorder: Barb Stockert, Administration
Purpose: Quarterly Meeting Update

AGENDA ITEM

/ RECOMMENDATIONS

OR ACTIONS

General Business

Gilbert Herrera reviewed the meeting protocol. Roll Call of the Executive Committee, A Team Leaders, and State Reps was completed. A list of the attendees is attached to these minutes.
Gilbert presented a special thank you to VGM for the rooms. He also explained that a conference line has been set up for members and Contractors to call in on. This number was made available to all attendees.

Review of January 21st, 2016 Meeting Minutes

Rich Pozeskymade a motion to approve them and Sheila Roberson seconded it. The minutes were approved.

CEDI Update

Stacy McDonaldpresented the CEDI Update. This is attached separately to the minutes.
Paula Koenig asked if suppliers would have to re-enroll with the change in the Jurisdiction Contractors. Stacy explained that they are not anticipating any changes, so Suppliers will not be required to submit new documentation. Suppliers are currently set up in all four MAC’s the same.

CBIC Update

Elaine Hensley provided the CBIC Update.
Round 1 is on schedule to begin the winter of 2017. She told everyone that the issues with the AO’s and BAO’s have been resolved for the most part. There are still a few issues in getting some registered so if you are having this problem please call the call center. The pre-bid evaluation has been done. If you didn’t have all your information on file you should have received a notice. The contractors review all the documents to be sure they have all the required documents. This also includes that financial information that is required.
Round 2 and Recompete is moving along. The problems seen here are with CPAP, O2, and Diabetic Suppliers. This all goes back to documentation issues and will hopefully be resolved soon.
Mary Stoner asked about the data suppliers are seeing when registering in Connexion. Elaine said that she would check and see why this is not matching up. She will check with the NSC and report back.
Kimberlie Rogers-Bowers asked about the cpap transition and the volumes of patients that are trying to get supplies but there is no documentation from the previous suppliers that they are compliant. This documentation is impossible to get and suppliers have to turn many of them away. This means that many patients are going without their needed supplies. Elaine explained that they continue to bring this to CMS as a high priority. She is aware that there was a meeting last week on how to address these issues and now patient owned equipment. She will follow up with them but is not optimistic their project team will respond with a process for suppliers to use.

Mary Stoner explained that this has been an ongoing issue since CB began. Is there someone at CMS to reach out to? Elaine said that Michael Keen and Joel Kaiser are their contracts or possibly Lawrence Wilson as the director.

Connexion is not up and running yet, but it is most important for all suppliers to register if they want to participate in the Competitive Bidding Program. The first item that will be seen there is the contract offer. This is a separate portal that is available on their website that is accessed by a specific login and password for each supplier. Disqualification letters will go out after the contracts have been accepted. This is so they can see what kind of offers and response they get.
There is not a hard, rigid deadline to sign up for Connexion. The CBIC encourages suppliers to get registered now because there is a 10 day window to accept or decline a contract.
Paula Koenig asked about Connexion and what it is being used for. It is used for bid offers and will eventually contain the forms and documents that are needed such as subcontracting agreements etc. This will all be available. This is driven by the information that is available in PECOS and allows for one AO and one BAO. PECOS allows for multiple AO’s but D Bids does not. Elaine said she will check on this. She said the person who signs off on the bid must be an Authorized Official (AO). Since Connexion only takes one person to register, this does not have to be the person that signed off on the bid.
Paula Koenig inquired about the Round 2 Recompete and said that wheelchairs are now paying correctly. When repairs are done and the RB modifier is used there are still issues. Paula asked if there was an update to this. Cindy said she has not seen one yet.

C2C Innovative Solutions

Dan Roach presented the C2C update. The Medical Director for C2C and this program is Dr. Janet Lawrence. Danstated the QIC is most commonly known as the DME for the 2nd level of appeals. They take their work very seriously and their corporate value and mission are to provide a service of high integrity and service. He introduced Virginia Carraher, Peggy Skaplen, and Emily Stroupe as other C2C staffwho were present. Emily’s position is Provider Outreach. Peggy’s is Policy and Medical. Virginia’s is Medical and Non-Medical Review. They will also be available throughout Med Trade to answer any and all questions members have.
CMS has made a change in the appeal process so they are now allowing a formal telephone discussion at the 2nd level of appeal so the supplier can present verbal testimony an additional documentation in support of their claim.The demonstration project will be done throughout Jurisdiction C and D on O2 and diabetic supplies. They will invite suppliers who have received denied claims based on lack of documentation. It is the Supplier’s decision if they want to participate in this project but they are hoping that most suppliers will do this. This is also limited to a maximum of 5 claims per NPI and will be initiated by C2C. Their notification will be sent via mail and suppliers will have 14 days to respond. Once the contact form is completed and returned to C2C communication should be able to be done via electronic means. This will be particularly helpful for those who do not get their letters timely.
CMS has also given C2C the ability to pull back claims that are at the ALJ. This is effective for dates of service 01/01/13 through present. If C2C feels a claim has the potential to be payable they will reach out to suppliers. The supplier will have 14 days to respond to their request.
A separate email and phone numberwill be established for the demonstration project.
C2C will be at the Noridian and CGA booth during the show. Please do not hesitate to stop and visit with them if you have questions.
More complete information on this project is listed below and included in the link and also attached to the minutes.
On January 01, 2016, CMS launched a new Demonstration with DME Suppliers that submit Medicare Fee-For-Service (FFS) claims, called the Formal Telephone Discussion Demonstration. The Demonstration will provide selected suppliers that have submitted second level appeal requests, called reconsiderations, the opportunity to participate in a formal recorded telephone discussion with the DME Qualified Independent Contractor (QIC), C2C Innovative Solutions, Inc. For more information on this demonstration, see the following link:
The CMS Fact Sheet is also attached to the minutes for your convenience.

Dr. Philip Benjakul from the RAC was not in attendance so no update was given.

Laurie Tan from the CMS Seattle Office. Was present on the phone. She did not have an update to present, however Mary Stoner asked about her previous question on PECOS. Mary forwarded Laurie examples of PECOS denials after the last meeting but nothing more has been determined. Mary explained that we verify the physician is enrolled when we provide service but when the claim is submitted it denies because they are not enrolled. Mary further explained that this is the tool that CMS provided to Suppliers and if it does not work we should not be held responsible for it. The VMS System provides different information than the medicare.gov does. Another problem could be when a physician is registered in multiple states and the information is not registered in the VMS system. This can happen when a physician is active in one state but not others. Their status is not accurately reflected because the VMS system only shows that they are deactivated.

Laurie responded that these are very valid points and asked for Mary to reconnect with her after the call so this can be further researched.

Jurisdiction C Update

Michael Hanna provided the update for CGS. It is estimated the timeline for Cigna to start the Jurisd. B Contract is July 1st. Roc Via is the program director for Jurisd. B. Currently he is in negotiations with the different state associations within Jurisd. B to help make the transition as smooth as possible. The following website can be accessed to gain information as it becomes available: There will also be updates presented during the Medicare Update Session today at 4:00 pm in the Islander B room.

Medical Director Update

Dr. Gurk introduced himself and explained that he has now assumed Dr. Moynihan’s role. She will be focusing on Part B. Dr. Whitten has moved into an administrative position but is still involved with everyone. Dr. Gurk used to be with Health Data Insights but has been with Noridian for about a year. He lives in Las Vegas.

Dr. O’Neal did not provide an update.
Sheila Roberson asked about ventilators. Dr. Gurk said the medical directors are having on- going discussions on these.
Dr. Gurk said the hot topic right now is IV Drugs and are under recurring discussion.
Deanne Birch asked about a statement she heard regarding RAC Contractors and that as of Jan. 2016 the look back period would only be 6 months instead of 3 years. Dr. Gurk replied that he had not heard of any changes on this but that the awarding of any RAC Contracts is still on hold.
Mary Stoner asked about the possibility of Medicare eliminating coverage on off the shelf prefabricated orthotics. Dr. Gurk has not heard anything.

POE Update

Cindy White presented the POE Update. This is attached to the minutes.
Cindy also updated DAC members that the Medical Directors are a huge asset to the Education Team and are very, very helpful.

Yondelis and Blincyto

Deanne Birch asked the following question regarding the recent release

of 2 Joint DME MAC publications released regarding coverage and coding
for 2 new drugs, Yondelis and Blincyto™.Could the Medical Directors
provide some insight as to why it wasdetermined that Blincyto
administration via External Infusion pumpwould be covered and included
under the EIP LCD benefit but Yondelisvia External infusion pump was
determined as NOT eligible for inclusion under the EIP LCD?

01/21/16 Dr. Gurk replied that he will take this question back and provide an update in Las Vegas.
03/01/16 Bill Noyes asked if Dr. Gurk could shed any light on the recent Joint Publication which denies payment via the DME benefit for Yondelis in the home. Dr. Gurk said that there has been much discussion amongst the DMD's and they are awaiting guidance form CMS regarding drug therapies that are initiated by a physician and then continued in the home. Bill stated that this was a challenge because Physician and HOPD's often do not have the means to support equipment and patients in the home 24/7 - that is what Home Infusion Providers specialize in.

PreviouslySubmitted Questions to CMS/Noridian and CEDI

Billing for Purchase: We need assistance from CMS on a claim processing

issue. Suppliers sometimes provide capped rental items to Medicare
customers that are not medically necessary per Medicare coverage
criteria. However, that item may be covered by Medicaid or another
funding source, as a purchase. The secondary funding requires a denial
from Medicare. Currently, any claim submitted for a capped rental item
with a NU modifier will be rejected on the front end as an invalid
code/modifier combination. This does not give an actual claim denial. Will
CMS please issue claim processing instruction revisions to allow
submission, and subsequent denial, for capped rental items provided and
billed as purchases with NU modifiers? Examples of applicable situations
can be provided.

10/28/15 Update: Most often these companies require a Medicare denial to process and pay the claim. The way it is currently set up the claim cannot even get into the system. Discussion followed and this will be researched. It is possible something could be done or an edit added.

01/21/16 Update: Cindy replied that there is not a solution for this. Mary Stoner asked if a modifier could be created or another means to identify claims in this situation. Cindy replied she will bring it back but because we are asking for a different pricing category they might not be able to do this.
03/01/16 Update: Cindy replied that there is not a modifier for this to get a denial, and it is unlikely that one would be created to satisfy a secondary insurance requirement. She said she understands it would be advantageous for suppliers to have something established from a secondary to allow for this. Mary Stoner asked Laurie Tan (CMS) for her thoughts. Laurie responded that she was not aware there was not a modifier. She said there is one on the Part B side. She asked for Mary to send her the information after the call and she will have the Central Office look at it.

HyQvia Coverage Policy /

HyQvia Coverage Policy: This was brought forth in Oct. 2015. The IV PEN team wanted to know when the HyQvia coverage would be added to the External Infusion Pump LCD. It was understood that there were numerous comments on this. Bill Noyes asked that this be added to the LCD. It is only seen in the joint publication. As a reminder: this was/is the concern noted: The issue is conflicting/contradictory language between with the EIP LCD and the HyQvia Joint publication.

The EIP LCD states: H. Subcutaneous immune globulin (J1559, J1561,
J1562, J1569) is coveredonly if criteria 1 and 2 are met:

The subcutaneous immune globulin preparation is a pooled plasma

derivative which is approved for the treatment of primary immune deficiency disease; and,

The beneficiary has a diagnosis of primary immune deficiency disease

(See Diagnosis Codes Group 3 that Support Medical Necessity section below).
Coverage of subcutaneous immune globulin applies only to those
products that are specifically labeled as subcutaneous administration
products. Intravenous immune globulin products are not covered
under this LCD. Only an E0779 infusion pump is covered for the
administration of subcutaneous immune globulin. If a different pump
is used, it will be denied as not reasonable and necessary.
But the HyQvia (which is Subcutaneous IG) Joint Publication specifies
the need to use an E0781 pump.
HYQVIA is administered using a programmable variable infusion pump
(HCPCS code E0781), that is capable of infusing a patient’s
therapeutic dose at infusion rates of up to 300 mL/hr/site.
Coverage is available for claims with dates of service on or after
September 12, 2014 when all of the following requirements have
been met:
The criteria for Subcutaneous Immune Globulin as specified in the
External Infusion Pump LCD are met, and
HYQVIA is administered subcutaneously through an E0781
pump that is pre-programmed, and
The E0781 pump is delivered to the Medicare beneficiary in a “locked
mode” i.e., the patient is unable to self-adjust the infusion rate.
The medical record must contain sufficient information to clearly
demonstrate that the beneficiary meets all of the requirements
specified above.

10/28/15 Update: It is a coding issue and is addressed in the

publication. They will take this back and look at it.

01/21/16 Update: Dr. Gurk commented that the Medical Directors

Are working on this and the IV Policy is being updated. He said to