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									                                                      CENTERS FOR MEDICARE & MEDICAID SERVICES
                                                                         Moderator: Carlene Randolph
                                                                               10-29-09/1:00 pm CT
                                                                            Confirmation #30430289
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                               Moderator: Carlene Randolph
                                    October 29, 2009
                                       1:00 pm CT

Gerry Nicholson: Okay, good afternoon everyone. Those of you here in the room and the many
                 people that are on the line today.

                 This is our sixth Medicare Provider Feedback Group Town Hall Meeting. So
                 this is the sixth year that we’ve done this.

                 I’m Gerry Nicholson and I’m the director of the provider communications
                 group at the Center for Medicare Management and CMS.

                 Now, the Center for Medicare Management is the component here that’s
                 responsible for the development, oversight and management of policy and
                 operational issues for the Fee-For-Service Program.

                 Good communication, of course, with the Medicare Fee-For-Service providers
                 is a priority for us and my group has the ultimate responsibility for ensuring
                 that the Fee-For-Service providers get accurate and timely information.

                 And to do so we’ve established an infrastructure that relies on our Medicare
                 (FI) carries a regional office provider outreach staff, the CMS Web site, our
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                                                       Moderator: Carlene Randolph
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outreach and product development efforts and, of course, our partnerships
with the national and local provider organizations who have really helped us
over the years to get the message out.

So the provider communications group is always interested in how we can do
better and we want any suggestions that you might have.

Today’s meeting is an example of one of the activities that we use and it helps
us to rely on feedback from individual providers regarding certainty for
service policies or operational issues.

The intent of the Medicare Provider Feedback Group was to create a quick
and flexible mechanism that allows a cross section of individual providers to
give us feedback when we need it.

So while we’re looking for candid and open feedback, note that we are not
attempting to reach consensus on any issues discussed today.

It is our intent today to listen.

Today’s discussion topics include 50/10, ICD-10, Medicare Contracting
Reform, Recovery, audit contractors and program integrity.

I know that’s a lot and that’s why we have ways for you to get comments to us
if we run short on time on any of these presentations.

I hope you find today’s event worthwhile. I know we will. Again, I appreciate
the time that you’ve taken to come and participate and be involved in the
Medicare Provider Feedback Group and without further delay I’m going to
                                                    CENTERS FOR MEDICARE & MEDICAID SERVICES
                                                                       Moderator: Carlene Randolph
                                                                             10-29-09/1:00 pm CT
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                 turn this over to Carlene Randolph who will be facilitating today’s discussion
                 and talking about ways that you can give feedback outside this meeting.

                 Thank you.

Carlene Randolph:   Thank you Gerry. Again, my name is Carlene Randolph. I work in the
                 Division of Provider Relations and Evaluations of the Provider
                 Communications Group. And, again, I will be moderating for this afternoon.

                 I’d like to let you all know that we have a number of topics so we’re really
                 looking forward to getting your feedback on those topics. But, again, we will
                 be moving quickly through the agenda this afternoon.

                 Our first topic of discussion will be 50/10 HIPAA standards for claims and
                 other transactions.

                 Christine Stahlecker, the Director of the Division of Medicare Billing
                 Procedures, Billing Applications Management Group, and the Office of
                 Finance Management will provide a brief overview of this topic.

                 Thank you Christine?

Christine Stahlecker: Thank you Carlene. Welcome everybody. Add my welcome to those that
                 have expressed their welcome today already.

                 I am part of the office of information services. As Gerry had said earlier she’s
                 the provider communication group director. I’m a division director reporting
                 to the business and application management group director.
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So the 50/10 project is actually being run out of OIS which is different from
OESS who will run the ICD-10 project and we’ll hear about that in a bit.

So I wanted to speak today about our 50/10 project. When I say 50/10 please
note that it’s short-hand because it does also include the National Council for
Prescription Drug Program Standards and that has got a short-hand to it, D.0.

So if I was really going to refer to our project it should be 50/10 and D.0
format updates.

We’ll get into some of that detail in just a minute. First let’s make sure I can
move the slides. I would like to go to the second slide. I seem to have lost the
presentation entirely.

Is he working on it? Okay.

I can just go over the agenda. I was going to give you a little bit of
background about the regulation that brought us these two standard format
updates and why we’re changing now and a little bit about how to get started
so that you can actually obtain some of the reference materials that you’ll

Then I’m going to talk a little bit about the Medicare approach to upgrading
the 50/10 and the D.0 formats.

I’ll give you some insights about how we’ve been working with our Medicare
administrative contractors and what you can expect from them in terms of
support and then some action steps that you could take immediately to get
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So first the regulation requirements. What was adopted in this modification
rule is really an upgrade to the X12 standards that should be familiar to you by
now. Those are the EDI, electronic data interchange standards adopted under
HIPAA in 1996. This is our first upgrade so we’re going from the 40/10
version or 40/10 A1 version to the 50/10 version.

And in the NCPDP world the suite for the retail pharmacy we’re currently on
a 5.1 version and we’re upgrading to D.0 and in the Medicaid world its using
version 3.0 for segregation claims.

And we do have within this rule an opportunity to use either the D.0 or the
50/10 for the retail pharmacy supply services and that’s based on trading
partner agreement.

On the next slide some of these features of the policy upgrade we have
regulation timelines defined in this rule. It went to great lengths to explain
some of the expectations to occur during the upcoming years and in 2010, not
that far away, the rule says the internal testing is to begin on January 1, 2010
and that would be for each of the covered entities involved in this upgrade.
And external testing would begin on January 1, 2011.

It did take lengths to say that one covered entity could not require another
covered entity to go earlier than the January 1, 2011 timeframe.

But many want to get started earlier and if there is an opportunity to test and
you have willing testing training partners that is permitted.

Onto the next slide. How do you get started? Well, the first thing you’re going
to want to have is access to the reference materials and these would be the
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                                                        Moderator: Carlene Randolph
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standard transactions and the old term was Implementation Guides and the
new term is Technical Report 3.

On this Slide, 6, we have some references to the Web sites, and
then there is a, I believe, that has the transactions.

This go round, covered entities must purchase the Implementation Guides.
Each individual covered entity must purchase their own. It’s not supplied to
you. They’re not for free anymore. And then if you needed to request changes
to standards we have the HIPAA/ reference Web site. But it’s a
little too late to make changes to this go round of transaction formats.

On Slide 7, who’s affected? I wasn’t quite sure what level we’d be speaking to
so we do have some fundamental educational materials here today.

All HIPAA’s covered entities are affected. That would be the providers, the
health plans or the payers and clearing houses. These are the covered entities
defined under HIPAA initially.

Now, this go round because of other regulations we’re noticing that the billing
service agents and business associates are also required to comply with the
covered entity regulations. Now, that’s not under HIPAA that’s under, I
believe, our regulations so you might want to have a look at that.

We will be expecting that the business associates are complying with some of
the aspects under HIPAA such as privacy and security.

On Slide 8, what actually is changing with this upgrade? The formats are
changing. They must be upgraded from the 40/10 A1 to the 50/10 and from
the NCPDP 5.1 to D.0.
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These new versions do bring in some changes to data element requirements.
In the current versions some elements that may be situational may now be
required or vise versa. In fact, some cases data elements are no longer present
in the 50/10 transaction formats that where present in the 40/10.

So you do need to do an analysis of what these transaction formation changes
are. You need to modify your systems that submit claims to payers or receive
remittances or anything that you’re submitting, any payer that you may be
exchanging an electronic claims status inquiry or response and of course, our
(HEP)s application will be upgraded as well for the eligibility transactions.

So software that you may be using will need to be upgraded. You’ll need to
look at your business processes to see if some of those data elements that are
now required will need to be incorporated into your data capturing

And just to support some of this analysis Medicare has compared the current
formats to the 50/10 formats and they are present on our Web site which is
listed here.

Finally, we’re suggesting to coordinate your transition to the new formats
across all the payers that you’re submitting to. Of course, we’re interested in
Medicare Fee-For-Service and hope that we’re your primary payer that you
exchange transactions with and can get started with us.

But it is a complete book of business on the providers side that all of your
exchanges with all of your payers need to be completed in a one year
transition timeframe.
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And we’ll look at that in a little bit more detail.

On Slide 9, again, our current formats. This is sort of a reference slide for you.
We have filled out the transaction identifier, the (A37)-I really means the
institutional claims. So this is a reference slide for you. These are the
transactions that are currently in place for Medicare Fee-For-Service, the
(A37)-I and P, the professional claim, client status inquiry response, that’s the
276, 277 transaction eligibility inquiry response the 270 and the 271 and, of
course, the remittance transaction.

Medicare Fee-For-Service still uses the TA1 today and we’ll use it in the
future in the functional acknowledgement that Medicare is using is the 997
today and that’s going to change. And of course we’re using the 5.1 version of
NCPDP for our DME claims processing.

On Slide 10, this slide is intended to convey to you how important it is to
Medicare that we have a smooth transition. We have over 99.8% of our
Medicare Part A claims are coming in on that (A37) institutional claim form
and over 95 - I think it’s about 96 in change percent of our carrier claims are
coming in on that (A37) professional claim.

And our contractors are simply not prepared to have an increase in paper
claims. We’ve been working very hard at decreasing our paper claims. In fact,
I have better numbers than what our slide shows. Yes, I only have 68%
decrease since ASCA enforcement began. It’s up to 80%. We went from over
about 11.8 million claims on paper in about 2003 and we’re down to 2.3
million claims on paper today and that was as of the end of ’08. So we haven’t
been able to run our annual numbers yet in ’09.
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So we have significantly reduced paper claims and are not looking to have any
fallback to that.

So it’s very critical to the Medicare program that we have a smooth transition
and we stay electronic and don’t have any fallback.

On Slide 11 we have - I wanted to go over the scope of change that’s going on
in the Medicare Fee-For-Service world just to give you an alert about what
we’ve changing in case you see any changes on your side.

We are, as part of our 50/10 project, we have drawn a line between the ICD-
10 project that Shannon’s going to speak to you about and our 50/10 project.

Fifty/ten is making way for ICD-10 code values. The infrastructure is really
being enhanced, expanded, within our 50/10 project and we like to term what
we’re doing in 50/10 as a Y2K like expansion of the diagnosis codes.

Just to say it the diagnosis codes under ICD-9 have a maximum length of five
positions and the maximum length under IDC 10 is seven positions. So each
and every diagnosis code can be a maximum of seven positions.

When researchers do look-ups down the road they may need to know what the
code value was drawn from, the ICD-9 code set or the ICD-10 code set. So
we’ve added a qualifier in our systems to say this code value is from 9 and
this other code value, when we get there for the ICD-10 project is drawn from
10. So we have done that expansion work.

Let’s see. We’re also introducing a new acknowledgement transaction which
is a 277 claims acknowledgement transaction that I’ve referenced on Slide 12.
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So we are replacing the functional acknowledgement, 997, with a 999
transaction and we are introducing the 277 claims acknowledgement.

That is not a HIPAA transaction. It is an EDI transaction, it is a national
standard transaction but it is not a HIPAA transaction. So Medicare Fee-For-
Service will be implementing this and we’re learning that many of the other
payers, many of the Blue Cross Blue Shield plans are also implementing that

On Slide 13 we are looking to have consistency of claim editing and we have
on our Web site today a spreadsheet that shows how each and every data
element in the claim will be edited under 50/10 and the particular error result
if it fails that edit what would be sent back to the provider.

We also wanted to point out that claim numbers are going to be assigned in
front-end systems so when you get back an acknowledgement saying if 100
claims came in to a MAC, two were bad, 98 where good the
acknowledgement transaction on the 98 transactions going back to the
provider will now include the claim number.

So you should have that very early in the process and be able to use that in
subsequent claim status inquires.

On Slide 14 is a reiteration of points I’ve already made about the expansion
and it’s important to note that an ICD-9 and 10, both the code sets, can have a
minimum of three positions. We’ve put an edit right up front in our front-end
systems that will not permit in an ICD-10 code value until it’s time and so we
won’t be letting anything come in too early.
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On - I’m going to skip right to Slide 16 and go over what you might expect
from your MAC contractors, our MAC contractors, your MACs serving you
for Medicare. We point out that each MAC does have a different front-end
system. And in the past we think that providers may have born the brunt of
variances in those front-end systems.

With the 50/10 project we’ve tried to come up with very consistent and
common processes so that the experience of the providers, should you be a
multiple jurisdiction provider, you’re experience with exchanging with
multiple MACs should be very similar. You’ll get back the same type of error
transactions for the same situation on a claim.

You may have a different connectivity and you’ll need to recognize the MACs
under their MAC identifier but for all intensive purposes we’re trying to
standardize the process efficiently. But any subsequent variation in the MAC
from your perspective the impact to you should be minimized.

We do have a series of MACs on Slide 16 that we are working with initially
and they are mentioned here and in our overall timeline we will be asking
these MACs to undergo a CMS certification before they engage in your
trading partner transition.

So we want to make sure that they’re operating under our requirements before
we permit them to start their transition work with you. So that certification test
will be executed in October of 2010 so that they’ll be ready to start to support
your transition work on January 1, 2011.

On Slide 17 - I’m going to skip over that. For your reference some of the
points that MACs might be sharing with you about requirements that they
would make known to you whether or not you’re going to be required to test
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for each transaction and identify those testing procedures and identify clearing
houses and the status of their capability with a 50/10 transaction, whether or
not they’d pass testing. So all of that will be supported information supplied to
you by the MAC.

And Slide 18, again, is our notice of our upgrade for error reporting. Again, I
mentioned that the 277 is a standard transaction and it’s not a HIPAA
standard. Our proprietary report that you may be used to in HPP 9 - something
from (fifth)s or CMS will not be generating those anymore. They’ll be
replaced by the 277 claims acknowledgement transaction.

So we’re suggesting we’ve had some information forms with clearing houses
and vendors to make this known to them so that they can take that transaction
and provide to you, providers, a human readable version of the error results.

On our Slide 19 is our overall timeline. Medicare Fee-For-Service is
implementing upgrades for 50/10 since October of 2008 so we’ve been
working on this project for quite a long time. 2009 was essentially dedicated
to development and in 2010 in large measure we’ll be system test focused.

We do have some development activities going on in the early parts of 2010
but the calendar year of 2011 will be devoted to supporting provider
transitions. So you’ll see January 1 Medicare Fee-For-Service will begin to
accept the 50/10 formats in production and the first step is for a provider to
submit a test transaction on January 2 and on January 3 you’re good to go.

That transaction can go through all of the Medicare suite of systems in a
production mode so we have quite a number of systems being fitted for the
upgrade to this transaction. On January 1, 2012 is when the 40/10 formats will
no longer be processed. So there is a full year for the transition and, of course,
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we encourage you to begin early and not get caught in the last minute rush of
things when turnaround of (unintelligible) might slow down.

On Slides 20, 21 and 22 we do have some upcoming communication
references. We’ll continue to disseminate information through our national
articles and news flashes. We’ll continue to have our national provider
education forms for planning our next bet which should start probably early
next year.

We do have some frequently asked questions in draft mode ready to be posted
to our Web site.

On Slide 21 we have a series of list serves that you may wish to subscribe to
to stay current with our communications and wanted to make note of our
provider partnership network. So we have a significant way of conducting

On Slide 22 we wanted to cause you to note our Web postings. We have
upgraded our Web site. There is a 50/10 tab on our Web and along with an
ICD-10 tab.

We have been speaking at national provider conferences and we’ll be
conducting regional office outreach.

On Slide 23 some steps that you could take now, we would suggest you get in
touch with your vendors, those that are supplying services to you in terms of
software or billing support, and find out when they’re going to deliver this
upgrade to you, because you’ll have some installation issues to get through
and some preliminary testing to get through.
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                Make sure it’s early enough and that prior to January 1, 2012 so that you can
                complete those activities. Making sure that this upgrade that you’re going to
                get does include the 277 claims acknowledgement transaction that your
                software vendor solution can accept that transaction and produce for you a
                human readable report so you’ll know how to correct any errors that may have
                been submitted as well as the 999 transaction.

                This is more of a technical failure of the format that may have been submitted.
                And then we would encourage you to evaluate your routine operations after
                you’ve done your data gap analysis to see if you do need to make corrections
                or enhancements to your procedures to collect additional data.

                And please stay tuned we’ll have additional national provider forums and if
                there are questions I will take them now.

Carlene Randolph:   Thanks Christine. We’re going to open the mic now to take one or two
                questions for this section. Due to the time constraints we ask that you keep
                your questions or comments very brief. I’m going to open it up to the

(Bob Burley):   Hi, I’m (Bob Burley). I’m here on behalf of the Healthcare Billing and
                Management Association and the question has to do with companion guide.
                There are a significant number of them currently prior to HIPAA there were
                about 400 different formats and after HIPAA there were more than 1000
                companion guides.

                So from a submitter perspective it got worse instead of better. We want to
                know how this is going to be addressed under 50/10 and whether the number
                of companion guides will be, first of all, limited to a small number and
                standardized to the extent possible.
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Christine Stahlecker: Excellent question. Thank you for asking it. While Medicare Fee-For-
                  Service gets a reduced bet just because of our Medicare Administrative
                  Contractor reduction and we’ll be down to 15 MACs. However, that being
                  your question, we have looked at standardized companion guides and notably
                  the CAQH or Core companion guide seems to be sufficient to satisfy the
                  Medicare Fee-For-Service needs.

                  It has a series of chapters to it. Some would need to be unique for MAC which
                  in an area for that would be like telephone numbers, help desk contacts, Web
                  site URL’s. So there are some specific needs to have uniqueness for telling a
                  provider how to connect or who to contact.

                  But really what you’re looking for is some standardized use of the transaction.
                  Medicare Fee-For-Service believes that we’ve taken great steps in that
                  direction and in any kind of companion guide where we would want to offer
                  up Medicare business rules or guidance about how to create a compliant (A37)
                  claim we would have those definitions included in chapters and supplied by
                  central office and then distributed to each of our MAC contractors.

                  So there would be some consistency from the MAC contractor expressing to
                  its provider population exactly what they’re companion guide would be.

                  So we’ve tried to reduce that tried to standardized where Medicare has
                  specific business rules. That doesn’t seem completely satisfying. What is the
                  next part?

(Bob Burley):     Well, the question was broader than that. The issue that we’ve had hasn’t
                  really been with the Medicare contractors. It’s the fact that because HIPAA
                  spans all insurance plans we’re dealing with over a thousand different
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                   insurance variations so while there have been some issues with Medicare
                   contractors the broad issue is the rest of the insurance industry which has to do
                   with the same HIPAA standards.

Christine Stahlecker: That is a fair question. I can only really speak to you today about the
                   Medicare Fee-For-Service world. OESS Shannon may take that question back
                   and have something else to say.

Carlene Randolph:     Thanks Christine. Operator, are there any questions on the conference

Operator:          Just to remind everyone, in order to ask a question from the phones please
                   press star then 1 on your telephone keypad.

                   You do have a question from (Kelly Urey).

                   Your line is now open.

(Kelly Urey):      Hi. My name is (Kelly Urey). I’m calling from DaVita Dialysis.

                   I just wanted to ask a question, you had mentioned on one of your slides a
                   provider partnership network. How can a provider find out how to join or do
                   you still list feedback from providers?

                   This is something I’m particularly interested in. We’re in 42 states and we’re
                   under multiple MACs and as the speaker in the audience just described we too
                   encounter, I guess, problems with other payers not specifically with Medicare
                   with HIPAA. But we’d just like to be part of a larger group that hopefully
                   could make some kind of difference or at least have some say in working with
                   other payers described towards compliancy with this.
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Gerry Nicholson: This is Gerry Nicholson and we do have a provider partnership network. It’s
                  primarily with organizations and associations but we would be happy to talk
                  with you and so you can give me a call or send me an email. I’m

                  Because you’re in so many states we can definitely discuss that with you.

                  Very good. Thank you very much.

Gerry Nicholson: You’re welcome.

Carlene Randolph:    Thank you. This is Carlene. Again, because of the time constrains I’m
                  going to give you the email address so that you can send your comments or
                  questions. That email address would be M as in Mary, S as in Frank, G as in
                  George at CMS dot HHS dot gov.

                  Our next topic will be Medicare Recovery Audit Contractors. Connie

Connie Leonard: Good afternoon. My name is Connie Leonard. I am the director of the division
                  of the Recovery Audit Operations here at CMS. And CMS has conducted a lot
                  of provider outreach over the last six to seven months so I’m really hoping
                  that everybody knows what a RAC is. So I’m going to go through my slides
                  really quickly so that I can hopefully get to some questions that the providers
                  on the phone may have.

                  So on Slide 2 of the presentation we kind of get CMS’s RAC program
                  mission. Obviously the goal of the RAC is to identify and correct improper
                  payments. So from a CMS perspective we want to take the next step.
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So the program has submissions, we then take those findings of identifications
and then bring them back to CMS if you corrective action so we can prevent
them from occurring in the future.

Obviously that helps out providers, they get to bill correctly the first time.
CMS (unintelligible) error rate and it helps protect the Medicare trust fund.

Slide 3 just gives a background of why do we have RACs and where did they
come from? The RACs program is (sectorally) mandated. It came out of the
Tax Relief and Healthcare Act of 2006 and before that it came out and before
that it came out of the Medicare Modernization Act.

And the difference between the RACs and our current Medicare contractors
that also do medical review is that the RACs are paid on a (contingency)
basis. So from a CMS perspective the RACs program is a self-funding
program. We get to keep a little portion of the funding to allow for the
administration and then the remainder goes back into the Medicare trust fund.

Slide 4 is just a quick breakdown of the region that we have four RACs in the
same region so the (DME) MAC region, you might be familiar with those.
Region A is diversified collection services. Region B is (CGI) Incorporated.
Region C is (Common) Consulting and Region D is Health Data Insights. And
they all have Web site’s specific to their contract with CMS and those can be
found at our Web site which is

So, what does a RAC do? Well a RAC does the same thing as any other
Medicare contractor that’s reviewing claims on a post-pay basis. They use the
same (MCD)s the same LCDs, the same CMS manuals, regulations, and the
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save coverage guidelines that your claims processing contractor uses the
RACs use too.

The difference is because the RACs have only tasks with reviewing claims
they can do a larger percentage of claims.

Our current contractors not only have lots of other work that they need to do
for CMS but they’re also limited by budget. The RACs aren’t necessarily
limited by CMS budget but limited by their own corporate budget so they can
review more claims in the client Medicare claim processing contractors.

The RACs also conduct the same types of reviews that the other Medicare
contractors. They do automated reviews which means on the (face) over the
claim they can determine an improper payment or they request medical
records and review the record and determination. When the RACs do that they
have to use certified code or certified therapist, registered nurses and all of the
RACs have a contractor medical director.

The RACs also can only go back until October 1, 2007 when reviewing

Now, that doesn’t mean any claims prior to that won’t be reviewed it just
won’t be reviewed by RACs. Usually before there it might be another
Medicare claims processing contractor or one of the program based

On Slide 6 it just gives you some updates about where we’re at right now in
the RAC program. We did award the contracts in February so we’re just now
nearing the end of our implementation and all the RACs have the data. They
all have new issues posted to their Web site. If you go back to your applicable
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RAC Web site in the region you’ll see a new issue tab. You can click on that
and you can figure out which issues are they currently reviewing in your in

And you’ll see if you look at all four of them that a lot of them have the same
issues up right now and they’re all what CMS might call black and white

An example would be an incorrect number of units billed on a claim. Again,
something that can be identified on the face value of the claim without the
review of the medical records.

Three of the RACs have actually issued demand letters. There were some that
went out in Region C from an outpatient hospital perspective and there were
some that have gone out in Region C and Region D from a (DME) supplier

All of the RACs have a 1-800 operational number that’s been in place now for
at least a good six months. If you have questions the first place you should
contact is your RAC, the second place is your claims contractors and the third
place is out on the CMS Web site we have our project officers where you can
contact somebody at CMS to get your questions answered.

And as I said, first when I started CMS has conducted along with the RAC
over 120 provider outreach questions. A lot of those where in person. We’ve
been to every single state including Puerto Rico and in addition we did
Webinars, conference calls, anyway that we can get the word out about the
RAC program we’ve been trying to take advantage and we certainly think our
state hospital and medical association’s been helping us conduct all of that
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Slide 7 is just a review (phase-in) strategy. There’s a lot of fear out there in
the provider community that CMS is going to, or the RACs are going to, begin
the medical necessity reviews and they’re going to come in and they’re going
to deny 100% of the providers claims and that’s not going to happen.

The RACs are going to start off with black and white automated issues. That’s
what I just talked about, what the (doc)s are doing now. They’re gong to move
into B or D validation, again, something pretty standard in the provider

There might be some conflicts review for coding issues that require a piece of
the medical record. That might be a lab report or some particular piece and
then once the RAC establishes themselves in that region they’ll slowly move
in to the medical necessity reviews but that will not happen before calendar
year 2010.

The one other thing I want to point out before I turn it over for questions is
that CMS does approve all the new issues that the RACs want to review. So
the RAC comes into CMS, they request to review in CMS along with an
independent validation contractor to make the decision regarding the RAC can
review that issue or not.

Once they get approval for CMS it then gets posted to the Web site. The
providers can have that confidence of knowing that CMS is aware of what the
RAC is reviewing and that the issues are out there on the Web site if the
provider wants to do their own type of quality assurance or compliance
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                So there are two questions I want to leave the audience with and hope they
                discuss; the first question is conjunction with the state hospital and medical
                association CMS has conducted it’s extensive provider outreach during 2009
                on the recovery audit contractor program.

                CMS has used in person meetings, Webinars and conference calls. CMS
                believes the majority of providers and physicians have a basic knowledge of
                the RAC program. Is this correct? And if not what additional outreach ideas
                do you believe are necessary? We certainly are trying to find every possible
                mean that we can to get providers information about the RAC program.

                Question two is the RACs pose potential new issues to the RAC Web sites
                after receiving CMS approval and before widespread review.

                Our providers and physicians content with the information currently supplied
                on the RACs Web sites and if now what additional information would you
                like to see posted on the RAC Web site? And I realize that some of you may
                not have been to the RAC Web site yet but since there’s a (time carried)
                accurate call that you can send in additional feedback we would certainly like
                to see those comments once you’ve had a chance to go to the Web site.

Carlene Randolph:   Thanks Tonya.

                We’d like to open up the floor for questions or comments. Thank you.

                Operator could you check on the conference line to see if there are questions?

Operator:       You do have a question from (Pat King).

                Your line is now open.
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(Pat King):        Oh, thank you. Actually my question was on the other, the first presentation. It
                   was about the MAC in my jurisdiction, South Carolina. There was a protest
                   notice about work order for the J11 MAC. Do you know where that stands or
                   is that something I just have to wait and find out? Are you familiar with that?

Christine Stahlecker: No. The MACs that we are working with are listed in our presentation. I
                   can give you the slide reference.

                   Those MACs that are not listed are in the various state of resolution.

(Pat King):        Yeah. That’s what I was trying to find out. I hadn’t seen anything.

Christine Stahlecker: But as far as our 50/10 project goes there will be a solution for providers
                   to begin their transition testing, testing to begin the transition, irregardless of
                   the status of the MAC award.

                   So very shortly we’ll have an announcement about how we’re going to
                   accommodate providers that need to test and get ready for 50/10 even if the
                   jurisdiction that they’re in the geographic area that they’re in does not have a
                   MAC in place for them yet.

                   We will have a solution for those providers.

(Pat King):        Thank you.

Christine Stahlecker: Okay.

Carlene Randolph:      Thank you, are there any other questions there?
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Operator:         You have a question from (Jim Purchase).

                  Your line is now open.

(Jim Purchase):   Thank you. Really I just had a comment. For us remote participants we didn’t
                  have any instructions on being able to download the slides that you are
                  presenting and that puts us at a disadvantage. I would like to know if that is
                  going to be made available?

Carlene Randolph:    Slides are available today, yes sir, and they will be for the next 30 days.

Connie Leonard: And I will also add that on the Web site we have a
                  RAC 101 presentation out there. It’s a little bit more comprehensive than the
                  nine, those slides that I just went through. So it’s probably about 25. So it’s
                  also a good place for providers to go to get more information about the RAC

Carlene Randolph:    Thank you. If there aren’t any other questions or comments our next topic
                  will be ICD-10, Shannon Metzler from the Office of E-Health Standards and
                  Services will be presenting.


Shannon Metzler: Thank you Carlene. Thank you everyone. My name is Shannon Metzler from
                  the Office of E-Health Standards and Services. We are the program
                  management office for the ICD-10 project.

                  I’m going to speak mostly today about what we’ve done so far within CMS
                  prepare the agency for ICD-10. We’re hoping that you can utilize a lot of the
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things that we’ve done in your own organizations to prepare yourselves as

So starting on Slide 3 just to give you a little bit of background on ICD-10 the
regulation was published on January 16 of this year mandating the use of
ICD-10 codes starting October 1, 2013.

ICD-10 CM and ICM PCS will replace the current ICD-9 CM volumes for
diagnosis and inpatient hospital procedures.

On Slide 4 ICD codes, as many of you in this room and on the phone are
aware of how they’re used, they’re used in many areas within the healthcare
sector including calculating MSDRGs, reimbursement, adjudicating coverage,
research and quality. They’re also used in standard transactions, payment
policy setting, care management and reporting.

Why are we choosing ICD-10 now? Sorry, I’m on Slide 5. The current ICD-9
codes that are over 30 years old, it’s very outdated, and it does not currently
reflect medical technologies. And many of the chapters within the ICD-9 code
book are full which results in new codes being placed in unrelated chapters.

For example, many of the cardiac codes are now being placed in the (I)
chapter which diminishes the integrity of the codes and resulting in further
burden on coders who spend more time trying to locate a code that’s in an
unrelated chapter.

ICD-10 really addresses these shortcomings. It has more space for more
codes. It has greater specificity, greater flexibility to add new codes now and
in the future and it does reflect current use of medical technology.
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On Slide 6 just kind of gives you a brief overview of some of the benefits of
ICD-10. Again, greater capacity and flexibility to add new codes, reflects
current medical technology and use of new procedures. It’s more descriptive
and more robust categories for precise coding and allows for more streamlined
reimbursement processes and richer quality of data for analysis.

It maximizes the value of clinical data and the benefits for an interoperable
EHR system it has the capacity to support future E-Health initiatives now and
in the future.

On Slide 7 I’ll just give you a little bit of a flavor for some of the impacts that
ICD-10 will cause within the industry. It will not be easy but we feel that the
benefit definitely outweigh the cost and the work that’s involved with
implementing ICD-10. Of course training will be needed and we here at CMS
are working to develop training materials to help the industry become familiar
with the new code.

There is some productivity loss that could be seen in the beginning of
implementing ICD-10 but it has been shown that this is very short-term.
Based on a 2003 field study by the American Health Information Management
Association these productivity losses where diminished within six months of
implementation, so they’re very, very short-term.

And, again, as - even Chris had mentioned a lot of systems are going to need
to be changed not only for 50/10 but for ICD-10. Fifty/ten is paving the way
as Chris mentioned for ICD-10 but it’s not taking into account the changes
needed for algorithms and logic and the edits that are used where codes are
used for these areas.
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So those will definitely need to be changed throughout the healthcare industry
not only with payers and software vendors but also at the provider level as

Okay, let’s switch to Slide 9. I’m just going to give you a little bit of
background on what we’ve been doing to date here at CMS. As I mentioned at
the beginning of my presentation the office of E-Health Standards and
Services is the Program Management Office per ICD-10 within CMS and we
are working with the other CMS components to coordinate implementing
ICD-10 throughout the agency.

We’ve also convened at internal ICD-10 steering committee who address
cross cut agency issues related to ICD-10 as well as taking into account high
level of 50/10 milestones and issues.

On Slide 10, again, we’re working to set up our PMO at this point in time for
ICD-10. We have contracted with a company called (Nobelist) who has been
tasked to help us plan for implementation. They’re working on developing an
integrated implementation plan as well as schedules as well as supporting the
individual components within CMS to develop their own plans and schedules
that will roll up into a master plan.

We’re also working on a compliance monitoring project. We’re currently
doing an environmental scan of industry readiness of ICD-10 and as we move
toward implementation monitoring how the industry is preparing for ICD-10
and making sure that you have the resources and materials needed for
successful implementation.

We’re also providing outreach and education. Our outreach and education
strategy that we are doing in OESS is a little different than what CMN is
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working on. We are targeting the small hard to reach rural non-Medicare Fee-
For-Service providers wrapping around what Medicare Fee-For-Service is
already doing. So we’re working hand-in-hand with CMN to make sure that
all aspect of the industry are targeted and that we don’t leave any stone
unturned making sure everyone has the resources they need to implement

On Slide 12 this is a very high-level timeline of the CMS ICD-10 program.
Our Phase 1 ended in September of 2008. Those preliminary results are
available on the CMS Web site.

We’re currently in Phase 2 which we just finished our ICD-10 impact analysis
which I’m happy to say will be posted on the CMS Web site by early next
week. It’s a very large document so be careful when you’re downloading it
and we’ve also begun Phase 3 which is the implementation program.

This includes implementation planning and program oversight working with
each of the CMS components to ensure that they have what they need to
implement ICD-10 within their own business area.

I’m going to skip Slide 13 and Slide 14. I’ve kind of already gone through
those. I’m going to skip right to Slide 17.

Over the past two years we have engaged in doing an ICD-10 impact analysis.
This was a very labor intensive project. We met various times with all CMS
components to gather information, to understand how codes are used in their
particular areas.

In looking at Slide 17 you’ll notice that this is internal to CMS. We did not
look at any organizations outside of CMS at this point in time. We are hoping
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that our results and our methodologies that we use will help you in doing your
own impact assessment for your organization.

On Slide 18 it kind of gives you a high level overview of our impact analysis
findings. Because of how big CMS is and how vast the codes are used within
the organization we chunked out our functions within business areas. As you
can see we have seven business areas all with an associated impact and on the
right side of the chart you’ll notice that we have functional areas. All those
functional areas comprise a business area.

So that’s kind of who we organized our CMS organization here because of
how large it is.

The impacts that we’ve identified where based, again, on multiple interviews.
A lot of time and research looking at how the codes are used within our
organization and as you’ll see a few of these are moderate to low impact. That
doesn’t necessarily mean that they’re less important. All of these areas are
very important and we need to make sure that they’re all implementing on a
certain schedule and making sure they have the resources.

But the moderate to lower impacts just have lower risks associated with
implementing ICD-10 within their business area.

On Slide 19 these are some of the impacts if CMS is not ready for ICD-10 and
as you’ll notice there’s a lot of interdependencies between the business areas.
Although we found that each business area had its own risk there’s multiple
risks associated with the interdependencies between business areas.

It’s very important because one business area cannot do their job until another
business area does theirs. So it’s very important to make sure you take into
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consideration the interdependencies within your organization to make sure
your timing and your schedules are on track.

For our impact analysis we created business process models. I’m on Slide 20.
We also developed some interaction diagrams. We also did risk assessments,
work effort assessments and an opportunity assessment.

And although it’s important to understand the risk and the work effort
involved we shouldn’t loose sight of the opportunities that ICD-10 will
provide. Having this information will assist everyone in really reaching
toward that ultimate goal of utilizing the codes to their fullest extent.

So that was a little bit different than our preliminary assessment where we
made sure that the components within CMS where aware of the opportunities
so as they’re implementing they can see the finish line.

Okay, on Slide 22 our current activities. We are developing a solution concept
and implementation plan for CMS. We’re creating options and
recommendations for how the agency will move towards implementation and
we’re also setting up tools and templates that CMS components can utilize in
tracking their progress towards implementing ICD-10.

On Slide 23 is a snapshot of our program work for a sound structure. As you
can see we have implementation planning and our PMO setup. We have cross
component strategies that we need to address through implementation as well
as individual business area changes and issues that we have to address and we
also have our outreach education and then of course our program management
to ensure that we’re on target and on schedule for implementing ICD-10.
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                Slide 24 kind of outlines our next step. We’re collaborating with all CMS
                components to make sure that the decisions that are being made - everyone is
                in agreement with them. We’re developing a baseline implementation plan.
                We’re organizing our PMO and governance processes. We’re doing a
                materials and activity audit within the agency as well as the industry to make
                sure that everyone has the resources that they need to implement ICD-10.

                We’re also doing message and materials testing. We’re preparing for
                communication opportunities. We’re looking at who we can partner with for
                this initiative and we’re base-lining surveys for monitoring industry readiness.

                So I know that was really quick. Again, we’re on limited time but I’m happy
                to take any questions you may have at this time.

Carlene Randolph:   For those of you here in the audience if you’d like to go to the center of
                the room to ask your questions or make your comments into the mic please do
                so now.

(Bob Burley):   Hi, it’s (Bob Burley) again on behalf of the billing industry. I have two
                forward-looking questions. One has to do with crosswalks. CMS has issued a
                (GEM)s. We’re already beginning to see commercial products being offered,
                that report to or actually do offer crosswalks. And the concern is that there
                will be an unknown number of those and they’ll be adopted by different
                insurers that will then put the submitters in the position of having to keep
                track of how many different code crosswalks and how to submit claims

                The second question has to do more with Medicare specifically LCDs, since
                all the codes will change the LCDs will have to be rewritten and there’s a
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                  question as to whether unspecified codes will be included or excluded from
                  the LCDs.

Shannon Metzler: I can try to answer those questions. In terms of the crosswalks I may have to
                  take your question back. We are afraid that there may be multiple iterations of
                  crosswalks out there that may conflict with each other. But at this time we’re
                  speaking with our (GEM)s.

                  I will have to defer to our friends in CMN on the crosswalk question. So
                  afterwards if you want to give me your name and number I’ll be happy to get
                  back to you on that.

                  In terms of the LCDs, yes, they will all have to be updated. We held our first
                  ICD-10 (jazz) session with our MACs about a week or so ago and that was
                  one of the issues that was brought up.

                  I don’t have an answer to that question at this time but, again, that is
                  something that we will look into.

                  We all have to be aware that we are still in the planning phases. Although
                  2010 seems like it’s right around the corner we do have a little bit of time and
                  a lot of the work that’s being done is for 50/10. Right now we’re looking at
                  more raising awareness and looking at the readiness of the industry and as we
                  get questions like this we will definitely address those.

Carlene Randolph:     Are there any other questions here in the audience?

                  I would also like to offer out to the audience that you can ask questions or
                  make comments about the previous topics that where mentioned here.
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                 Operator, are there any questions or comments on the line?

Operator:        You have a question from (Carol Smith).

                 Your line is now open.

(Carol Smith):   Thank you. The gentlemen earlier asked about the specific slides for this
                 presentation for those of us that are here via telephone. In going to your CMS
                 Web site can you narrow down for me where I might be able to find these
                 referred slides?

Carlene Randolph:   Okay, the slides can be located at
                 Click on the first spotlight and it gives you everything that you’ll need, all the
                 slides will be located there.

(Carol Smith):   Thank you very much.

Carlene Randolph:   Operator, next question?

Operator:        Your next question comes from (Dina Sledge).

                 Your line is now open.

(Dina Sledge):   Thank you. We had a question in regards - we’re a specialty lab and with the
                 codes changing with the ICD-10 and we still may be using the ICD-9, how is
                 that going to impact our claims that the hospital is sending lab work to us and
                 we have to reconfigure them back to the ICD-9?

                 How is that going to affect our claim?
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Shannon Metzler: This is Shannon Metzler. I will have to take that question back as well.

(Dina Sledge):    All right Shannon thank you.

Shannon Metzler: Your question to the email address that was given earlier, I will be happy to
                  answer that.

Carlene Randolph:     That email address would be M as in Mary, F as in Frank, G as in George
                  at CMS dot HHS dot gov.

(Dina Sledge):    Thank you.

Carlene Randolph:     Thank you operator. Any other comments or questions?

Operator:         Your next question comes from (Cathy Aroseco).

                  Your line is now open.

(Cathy Aroseco): Thank you very much. My question is actually about RAC. I have yet to see a
                  phase-in strategy for red states and it’s actually a two-fold question and the
                  other part of that question would be when you issue that phase-in strategy are
                  we talking about Part A and B or both?

Connie Leonard: We reviewed the phase-in strategy that we have out there is across all provider
                  types. It’s not specific to Part A, Part B or your new claims.

                  In the demonstration we did start out with Part A and then slowly move into
                  Part DME but if we go with the national program all claim types are eligible
                  for review. It is approved by CMS and when you go to the RAC Web site
                  they’ll list the provider types and right now you can see some that are
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                  approved just for DME and some that are approved from an outpatient and it’s
                  (addition) perspective.

(Cathy Aroseco): Okay. And then as far as the phase-in strategy for red states is there one? I
                  haven’t seen it. I’ve seen green, blue but not red.

Connie Leonard: Yeah. We have a couple of different colors out there on our Web site from a
                  MAC perspective. We started out the blue, green and yellow was an outreach
                  MAC and we started out with the green and yellow states and we moved into
                  the blue states.

                  Now that all of the outreach is completed all of these states are red. That
                  means that we completed all the outreach. We just completed Maryland
                  yesterday. We did a couple of MACs out. They had Maryland and Virginia
                  still not red but all of them are red now and all of the states have completed
                  the provider education and the RACs have a claim so all of the states are now
                  eligible for RAC review.

(Cathy Aroseco): Okay, thank you.

Carlene Randolph:     Yes, operator, are there any other comments or questions?

Operator:         You have a question from (Rowena McWharper).

                  Your line is now open.

(Abby):           Hi Shannon. My names (Abby) and I’m from the Cardiovascular Institute of
                  Forth Worth. And my question is on the LCD just saying that we’re so far
                  away from that implementation, when can the providers see that their LCDs
                  are going to be updated?
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                  Do you have a timeframe on that?

Shannon Metzler: No, we do not have a timeframe on that at this point.

(Abby):           Okay, but they don’t have to be updated until the actual implementation of

Shannon Metzler: Yes, that’s correct.

(Abby):           Okay, thank you Shannon.

Shannon Metzler: You’re welcome.

Carlene Randolph:     Thank you. Are there any other questions or comments?

Operator:         Your next question comes from (Harvey Perry).

                  Your line is now open.

(Harvey Perry):   Hi, thank you very much for taking my question which is will there be a grace
                  period for the ICD-9, I’m sorry, ICD-10 changes?

Shannon Metzler: No. There will be no grace period. We’re not planning on any contingency
                  plans. All covered entities will need to be submitting codes on or after
                  October 1, 2013 and I should preface that the codes are based on data service.

                  So any procedure or office visit and so forth on or after October 1, 2013 will
                  need to be submitted with an ICD-10 code.
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(Harvey Perry):   Okay. Thank you very much.

Carlene Randolph:     Yes, operator are there any other questions or comments?

Operator:         Your next question comes from (Mary Stoner).

                  Your line is now open.

(Mary Stoner):    Yes Shannon - and I actually just wanted to also ask the question about a
                  phase-in strategy, if there would be some timeframe that those claims would
                  be - for the ICD-9, 10 would be phased in where we would - just like right
                  now with the (P) code system where we actually get an error message but yet
                  the claim is still transmitted, so we would - I guess we were hoping there
                  would be a phase-in strategy for that as well.

                  I too am interested in information regarding multiple crosswalks as well as
                  information on LCD updates as well.

Carlene Randolph:     I apologize (Carla), could you clarify that? We can barely hear you on this

(Mary Stoner):    Yes. Is that any better?

Carlene Randolph:     Yes, that’s a lot better.

(Mary Stoner):    Okay, thank you. I was just saying that as well in addition to the previous
                  caller I was questioning the ability to have some type of phase-in program just
                  like we do with the current (P) code system claims still can transmit up until
                  January but at least we get some type of warning message. And so I guess I
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                  was hoping that maybe there would be that type of phase-in strategy with the
                  ICD-9, 10 program.

                  And, again, also expressing concern about multiple crosswalks and LCDs as
                  previously stated in this call.

Shannon Metzler: Yes. Unfortunately we are not doing a phase-in. Again, any service that is
                  provided on or after October 1, 2013 must be submitted with an ICD-10 code.
                  So, again, there will be no phase-in and in terms of the crosswalks and the
                  LCDs that we are still strategizing how we are going to address those and we
                  will get back to you and let the industry know of the guidance that we’ll

                  And is there any - did you have a date as of to the earliest time that we can
                  start using those ICD-9, 10s?

Shannon Metzler: I’m sorry, can you repeat that?

(Mary Stoner):    Yes. Is there a specific date as to the earliest time that we can start
                  transmitting using the ICD-9, 10 codes?

Shannon Metzler: We cannot start accepting ICD-10 until October 1, 2013. So until that time
                  please still submit using ICD-9.

                  Is that what your question was?

(Mary Stoner):    Yes ma’am. Thank you.

Shannon Metzler: You’re welcome.
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Carlene Randolph:     Operator, are there any other comments or questions?

Operator:         Your next question comes from (Jack Bradley).

                  Your line is now open.

(Jack Bradley):   Hi, yes. I was just curious since the RAC auditors work off a contingency or
                  percentage of what they collect, who do they answer too and who’s their
                  oversight committee to make sure that they’re not motivated by just collecting
                  money for themselves?

Connie Leonard: The recovery audit contracts are contractors of CMS. They have a contract
                  with CMS and they have a statement of work. The statement of work is
                  actually public. It can be found on the RAC Web site that I mentioned earlier;
         and CMS believes we have lots of (P) codes in place
                  to make sure that the RACs are not just identifying inaccurate overpayments.

                  For example, if the RAC loses at any level of appeal the RAC has to return the
                  contingency phase. That’s even - it’s at the first level and all the way through
                  the ALJ, the Medicare Appeals Counsel and federal court.

                  Another thing is, as I mentioned, earlier, CMS is approving all of the RACs
                  new issues so CMS is aware of what the RACs are doing and will approve an
                  issue with this again to CMS policies.

                  Again, that statement of work is public and out there and, again, this second
                  piece is every year CMS has to do a report to congress on the RAC program.

                  We also make that public. The 2009 report will hopefully be out shortly after
                  the first of the calendar year.
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                  We always post it to the RAC Web site and this year it will be pretty much
                  about the implementation process that occurs this year.

(Jack Bradley):   Okay. Another question. I kind of get in late. Is it - everyone will eventually
                  have to do electronic billing? How about the little small offices? It sounded
                  like the first presentation was leaning towards everyone would eventually
                  have to do electronic billing. Is that correct?

Christine Stahlecker: That’s an interesting question. Currently the ASCA, the Administrative
                  Simplification Compliance Act has some waiver provisions in it and recent
                  legislation has not changed that.

                  So those provisions still are in place. The enforcement that I spoke of earlier,
                  this is (Chris Soligar), we took those requirements and actually those
                  providers that did not qualify for the waivers are required to bill

                  Those savings that I mentioned earlier where we have dramatically reduced
                  the number of paper claims are in part from that ASCA enforcement. Just
                  looking at the providers that must submit electronic claims but in large
                  measure we’re finding that providers that may qualify for waivers are also
                  submitting electronic claims just for its efficiencies and improve the payment
                  process when you submit an electronic claim you can receive your payment a
                  little bit earlier.

                  So we’re seeing that even though providers may qualify for waivers they
                  choose to submit electronically and we’d like to see more of that actually.

(Jack Bradley):   Thank you.
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Christine Stahlecker: Okay.

Carlene Randolph:     Again, for those of you who are unable to get the instructions for the
                  download, please take notes that the link would be
         Click on the first spotlight and it will
                  give you all of the slides.

                  I’d like to also inform all of you, all the responses to the questions asked today
                  will be shared with the members of the Medicare Provider Feedback Group by
                  the email list.

Carlene Randolph:     Operator, are there any other questions or comments?

Operator:         You have a question from (Michael Preditor).

                  Your line is now open.

(Michael Preditor):   Yes, thank you. This is Dr. (Michael Preditor) calling. I’m a chiropractor
                  in Pennsylvania and I’m just entering into the insurance world. Today’s
                  program has been very interesting to me especially showing me what I don’t.

                  Can you recommend a basic text for an introduction to Medicare that would
                  guide a provider, a single practitioner through the maze that obviously leads to
                  some of the other avenues that you’re discussing today? As well as you just
                  mentioned, the gentlemen just mentioned, the waiver process. Where do I find
                  the qualifications to obtain a waiver certainly at this point until my feet are
                  much wetter than they are today?

Carlene Randolph:     Just a second sir.
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Gerry Nicholson: This is Gerry Nicholson and we offer a lot of educational products to
                  providers especially someone like yourself starting out. Actually we have a
                  rather extensive product for residents and interns as they’re finishing their
                  programs and becoming Medicare billers.

                  So if you send me your name and address I will send you information. You
                  could also find this on the CMS Web site which is and then
                  in the search box look for the Medicare Learning Network. That’s our official
                  trademark for Fee-For-Service provider information.

                  The other good resource for you is the contractor that processes your claim
                  can also help you in determining exactly what products you need and we work
                  very closely with those contractors in our education effort.

                  So please feel free to send me an email at
                  or go to our Web site, look at the Medicare Learning Network or contact your
                  contractor or all three.

                  The second part of your question I’m going to turn it over to Chris.

Christine Stahlecker: I’m sorry. I was focused on the first part of your question too. Could you
                  repeat that second part for me please?

(Michael Preditor):   Yeah. The gentlemen mentioned that there are conditions for waivers for
                  electronic billing and where would I find those conditions for waivers?

Christine Stahlecker: Oh, for the ASCA enforces there are certain - again, on our Web site there
                  would be documentation that would spell that out for you and so you have
                  access to our Web site. In general terms there are a few particular claim types
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                   such as (blue shot) roster billing and it does depend upon the size of a
                   professional practice that there are fewer than ten full-time employees in an
                   institutional fewer than 25 full-time employees.

                   So there are certain provisions both based on the size of the organization or
                   the particular claim type that’s being billed. And all of that is spelled out on
                   our Web site. You should be able to find that if you look for ASCA or
                   Administrative Specification Compliance Act.

(Michael Preditor):    Okay. And that’s under the www.cms etc?

Christine Stahlecker: I’m sorry. It’s kind of hard to hear that. Could you say it again please?

(Michael Preditor):    I’m sorry. That’s under the CMS Web site?

Christine Stahlecker: Yes, that’s on our Web site, on the Web site.

(Michael Preditor):    Great. Okay, thank you so much.

Carlene Randolph:      Thank you. Operator, are there any other questions or comments?

Operator:          Your next question comes from (Nancy Anderson).

                   Your line is now open.

(Nancy Anderson):      Thank you. Yes, my name is (Nancy Anderson) and I’m calling from
                   (unintelligible) Hospice.
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                  Back when the (A37) claim formats where put into use the - one of the
                  requirements for hospice providers is to send a notice of election to lock the
                  Hospice patient into the benefit.

                  Those used to be able to be submitted electronically and when the (A37)
                  format came about a few of the MACs have told me that they were never
                  considered in that format so we have to manually key those now into the floor
                  shared system or the fiscal shared system.

                  And I was wondering with the change to the 50/10 format, has the issue of
                  submitting those notice of elections electronically been revisited in that we
                  might be able to expect to see that as Hospice providers?

Christine Stahlecker: Quite frankly we did not extend the scope of this project to address that
                  particular transaction format. It is interesting and if you would like to submit
                  some additional information please send us an email at the site mentioned
                  earlier and we could take that into consideration for our future planning.

(Nancy Anderson):     Okay. Thank you very much.

Christine Stahlecker: Okay.

Carlene Randolph:     Okay. Thank you operator we’ll take one more question from the
                  conference line.

Operator:         You have another question from (Heather Jones).

                  Your line is open.

(Heather Jones): Hi, I’d like to get back to the RAC discussion as well.
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Carlene Randolph:     I’m sorry. We cannot hear you. Could you speak a little louder?

(Heather Jones): Sure. I’d like to go back to the RAC conversation. I’m with the State
                  Homecare and Hospice Association, and we’re in North and South Carolina
                  and so we’re covered by (Conley). And they were here to work with our state
                  hospital and medical association several months ago, and we were not
                  contacted and provided an opportunity to participate in that outreach. And we
                  have tried to contact (Conley) to determine whether or not they would be
                  working with homecare and Hospice providers in our state to provide some
                  outreach. And I just didn’t know if they considered the outreach complete at
                  this point or if we could expect outreach specific to our providers.

                  In talking to our colleagues around the country that’s sort of been the case that
                  home health and Hospice has been left out of the outreach opportunities.

Connie Leonard: Well, in some states we did work with the hospital and medical associations to
                  include all provider types but the outreach is actually an ongoing event and
                  the big push of the onsite visits is complete but the outreach will continue in
                  the form of conference calls.

                  In fact, we’ve been doing a lot of conference calls with some of the specialty
                  associations. So if you can send me the contact information for the association
                  we can certainly get in touch with them and see if we can do a conference call
                  or Webinar for their membership.

                  My contact information is Connie, its C-O-N-N-I-E dot Leonard, L-E-O-N-A-
                  R-D at

(Heather Jones): Thank you.
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Carlene Randolph:   Thank you. We’ll move onto the next topic which will be program

                Kim Brandt from the Program Integrity Group, Office of Finance
                Management will be presenting.


Kim Brandt:     Great, thank you very much. Glad to be here. I’ll address a number of
                questions and we had a few questions come in but I think that the questions
                that came in where actually ones that were more for the Centers for Medicare
                Management so I’m going to pass those off to them.

                But I wanted to talk to you briefly about the fact that the fraud and abuse
                issues in general have been a huge focus of this administration. If you did
                watch 60 Minutes on Sunday night you’ll probably have noticed that there
                was a big piece on Medicare fraud. And it certainly has been hitting the news
                almost every day including today because the deputy secretary, William Core,
                for the Department testified yesterday in front of the Senate Judiciary
                Committee talking about the need for us to continue to be more in the area of
                fraud and abuse.

                And it’s certainly been a focus of the Obama Administration with respect to
                healthcare reform because of the fact that it is something that has been cited
                by both the President and the Secretary and Attorney General as a big area of
                focus for this administration.

                The result is there are a number of new tools out there which you all can use
                as you seek to get information about what’s happening with the fraud and
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abuse activities. One of which I wanted to bring to your attention is And that is the Web site,, that has most of the information including press
releases, any recent announcements, remarks that the secretary or attorney
general or others make about healthcare fraud and abuse all in one place.

So it’s a good one-stop resource to sort of know what’s happening.

But I think the particular interest to all of you, and I know that certainly the
thing that my team and I are really struggling with as we work through how
we can do a better job of fraud and abuse and program oversight at CMS, is
how is it that we are going to be able to strike that right balance?

How is it that we can go after the people who are deliberately and
methodically defrauding the program but still not put too much of a burden on
those who are legitimate and honest providers and suppliers doing the right
thing, following the rules for Medicare and trying to be good program

And I think that one of the things that would be particularly helpful and that
we would appreciate feedback from this particular group about as we go
through this process is ideas and suggestions that you all have as to how we
can do a good job of sort of communicating with you all - what’s happening in
the areas of fraud and abuse, but also how we can continue to try to strike that
right balance. And certain provider or supplier types, for instance durable
medical equipment, we have had to put a lot more program safeguard types of
things in place because of the (provacity) of the fraud in a particular area.

We haven’t had to do as much of that in other program areas because the
(provacity) of the fraud hasn’t been as bad but we are very conscious of the
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                fact that in durable medical equipment much as other areas there are the
                majority of providers who are legitimate honest suppliers who are really
                trying to do the right thing. And our struggle at CMS is always trying to make
                sure to hit that right balance.

                So, for today in addition to any other questions that you all have I would
                welcome any feedback that you could give, either through today’s forum or as
                a follow-up to the folks here at the town hall meeting coordination center, on
                ways that we at CMS can continue to strike that right balance and try and
                make sure that we’re sort of hitting, seeing, the right stride if you will between

                Fraud and abuse is going to continue to be a big focus of this administration. I
                think the fact that the secretary and the attorney general have formed the
                Healthcare Prevention and Fraud Action Team and that there have been such a
                big focus both in the media and elsewhere on the fraud and abuse issues
                means that it’s going to stay a focus for the foreseeable time being.

                But in addition to us wanting to do things that we can to internally improve
                our programs we really do want to partner with all of you and have input from
                all of you as to ways that we can do that in a way that hopefully doesn’t tip the
                balance too far so that there’s a lot of added burden on all of you who are the
                legitimate and honest providers and suppliers.

                So with that I’ll open it up to questions and use the rest of my time to take any
                questions or any suggestions that you all have.

Carlene Randolph:   Are there any comments or questions here in the audience?

                Okay, operator, I’d like to open the line for questions and comments.
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Operator:        You have a question from (Pat King).

                 Your line is now open.

(Pat King):      My questions concerns the previous presentation. I’m sorry. It was about the
                 MSBRGs and will the implementation of ICD-10 and its specificity create a
                 need to expand the MSBRGs or how will that work?

Carlene Randolph:    Yes, thank you. Shannon’s coming on the line.

Shannon Metzler: I will admit, I’m not the MSBRG expert but there has already been work to
                 convert the MSBRGs for ICD-10 but from my understanding in order to do a
                 complete conversion there will need to be data to see changing the MSBRGs
                 to ICD-10.

                 So I believe and I can follow back up on this that they will still be using the
                 ICD-9 codes until we have enough data to convert them to ICD-10.

(Pat King):      Thank you so much.

Shannon Metzler: Which is about two years.

(Pat King):      Thank you.

Carlene Randolph:    Yes, operator, are there any other comments or questions?

Operator:        Your next question comes from (Greg Pang).

                 Your line is now open.
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(Greg Pang):     Hi, my name is (Greg Pang). I am the executive director of Community Home
                 Health and Hospice in Washington State and on the topic of RACs my agency
                 was under the Hospice (probe list) this past year and $400,000 that was denied
                 we have recovered through four levels of appeal $350,000 of it.

                 The most recent nine claims that went to the (ALJ) where all overturned and
                 denials where overturned. And so my question is our agency spent two years
                 trying to recover this unjustly denied care and what safeguards are there for us
                 either for cash flow but also getting back to those original auditors? Who’s
                 holding them accountable because all of the denials that they issued to us have
                 been overturned?

                 So that’s my question.

Connie Leonard: You’re asking about things that are overturned on appeal and what happens
                 with them? Like normally the contractor would then adjust the claim again
                 and the money would be paid back to the provider. In the event that the
                 provider had already repaid the money. From a RACs perspective CMS takes
                 over (unintelligible) from their next invoice.

(Greg Pang):     That wasn’t quite my question. My question was about the recovery audit
                 contractors, they are paid a commission based on what is found to be
                 inappropriate care but we have found in our experience over the past year, two
                 years, that 95% of what was originally denied has been overturned. And so
                 there has been so much wasted time and expense. I mean, I believe that the
                 RACs need to be held to a higher standard of what they deny if they have
                 found that most of their claims get overturned, who’s holding them
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Connie Leonard: Well, actually, before the end of this calendar year CMS will be releasing
                  some updated appeal statistics from the demonstration and will show the
                  various level of percent to appeal to each level.

                  And at the last update which was just in August of 2008 it did not include the
                  ones near the end of the demonstration but less than 10%, in fact it was around
                  7%, of all of the appealed cases where actually overturned at any level.

                  I think what you might be talking about are cases that are going up to the
                  administration (role) judge and normally it’s typically if you just look across
                  Medicare as a whole and not even just the RAC cases it would typically get
                  reversed at the higher level.

                  CMS certainly has taken steps for the (oasis) but, again, the new issue of
                  review process and that CMS is the (unintelligible) of those issues for the
                  RACs even begin reviewing. And as we certainly just actually this week, just
                  on Tuesday, I did a RAC 101 presentation to the Office of Medicare here in
                  appeals and the administrative (role) judges so that they knew about the
                  program and about how they operate.

                  We’re certainly working with them from a budget perspective because we
                  certainly know that there have been delays in addressing those hearings.

                  But CMS believes we have the right parameters in place to make sure the
                  RACs are making accurate identification.

                  And, like I said, with the approval issues and the RAC (losing that vicinity) I
                  believe that’s a big incentive for a RAC to identify an accurate determination
                  because even if that case gets overturned at the (ALJ) level the RAC is still
                  going to have repay the contingency fee. And then they will also have to
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                  attend a hearing and extend the staff time. It goes right along with the (ALJ)

                  And in some cases, that’s even broadening the (account). So it can get quite
                  costly from a RAC perspective. They’re not going to want to review cases that
                  have a high probability of getting an appeal because it’s going to end up being
                  very costly for them.

                  This is one of the things that we’ll be tracking though and you’ll get to see in
                  our CMS annual report to congress what the appear rates are and not just
                  overall but at each level because it’s certainly something that we watch and
                  work very closely on.

(Greg Pang):      So if a particular RAC has a high percentage of overturn rate there will be
                  consequences for that RAC I assume?

Connie Leonard: Absolutely. The contracts that CMS has entered into they’re what’s called a
                  base (U) in option years and the appear reversal rates are just one of the areas
                  that CMS will be reviewing every year when we make a determination to go
                  forward with their contract for another year or not.

(Greg Pang):      Okay. Thank you.

Carlene Randolph:    We have one question here in the audience.

Man:              I had a question and a comment for Kimberly.

                  The 15 minutes, obviously, the (few) cases that where tried there where
                  mostly from false providers on the 60 Minutes. And you talked about a
                  balance, clearly providers are charging over payments or underpayments are
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              sort of either in the smaller improper payments category versus the (false)
              provider (dealer) fraud.

              What especially are you doing that are either an enrollment time or real time
              payments mode to stop the false provider?

Kim Brandt:   I - just a recap I believe the question is what are we doing to sort of help with
              the false providers in real time or with respect to enrollment? And to answer
              your question there are a number of things we’re doing. First of all, with
              respect to the false front type of providers that they showed in the 60 Minutes
              episodes, effective October 1 of this year all durable medical equipment
              suppliers who are participating in Medicare, unless they meet one of the
              exemptions of being a particular type of supplier, are going to have to be
              accredited - which means they have to go through a very rigorous
              accreditation process by an organization such as the Joint Commission or
              other deemed accredited organizations.

              They also will have to post a $50,000 minimum maturity bond which will be
              another way that we can ensure that they are putting up capital as part of their
              participation in Medicare.

              The third thing that we are doing is that thanks to the additional discretionary
              money we got through this years budget process we have increased the
              number of onsite inspectors. We have an area such as South Florida if you
              watched 60 Minutes they indicated we only have had three.

              We also do have people from our contractors in our field office which help but
              in terms of enrollment people we only had three from our contractor. We are
              adding additional (staff) to the contractor so we will have more people going
              onsite to ensure that once those people get in the program that they continue to
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              be there and provide it. But also we’re doing much more rigorous pre-
              screening with the accreditation onsite visits and other types of things to
              ensure they’re legitimate on the front-end.

              So, we are hopeful that all of those things together are going to make a big
              difference particularly with respect to the areas that have been most
              vulnerable to ensure that we keep that balance and there’s only legitimate

Man:          I also had a suggestion because you asked for a suggestion. In either the
              intelligence community or the financial services community, what they do is
              move to a risk based kind of compliance program and where they can actually
              score essentially (partlies) or products or things that are especially risky at any
              given time? And focus more on MAC versus sort of the overall fresh approach
              of (paying) scenarios and going up (everybody).

Kim Brandt:   Yeah, and that’s an excellent point that was in the intelligence community the
              risk-based score, if you will, we are now doing the same thing with respect to
              our enrollments or durable medical equipment suppliers. We actually have
              certain scores that are assigning to those suppliers to help determine how often
              we’ll visit them.

              And we’re also exploring whether or not we’d want to do that in high risk
              areas of the country or other places so that we could better focus more. That’s
              an excellent suggestion and something that we’re currently looking into
              beyond the CME.

              So thank you for your suggestions.
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Carlene Randolph:   Thank you. Operator, are there any other questions or comments on the
                conference line?

Operator:       You have a question from (Pam Tower).

                Ms. (Tower) your line is now open.

(Pam Tower):    Okay, thank an ESRD physician and we encounter...

Carlene Randolph:   We cannot hear you (Pam).

(Pam Tower):    Hello?

Carlene Randolph:   Hello, if you could speak a little bit louder. We can’t hear you hear on this

(Pam Tower):    Can you hear me now?

Carlene Randolph:   Yeah, we can hear you now.

(Pam Tower):    Okay. I am calling from a nephrologists office, single solo practice, and we
                encounter a lot of primary, secondary coverage issues. I guess I’m addressing
                more to the last statement that was presented as far as the program integrity.

                Is there any way or is there a specific office that we could work with in trying
                to get the Medicare primary, secondary coverage straight? Because we will
                have patients who qualify for the Medicare based on ESRD and also have dual
                entitlement and we can go up to two years back and forth between a (DEHD)
                and Medicare, both paying primary, and trying to get the money sent back and
                neither one like trying to decide who actually is the primary payer.
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Carlene Randolph:   I think that’s one where we’re going to need to maybe get some
                information and get back to you because I’m not sure that any of us here at the
                table, unfortunately, can get the answer to your question.

                So perhaps, I don’t know if there’s an email box but we’ll need to get back to
                you on it. I apologize. I don’t think any of us at the table are able to answer
                your question.

(Pam Tower):    Well, I mean, all I hear is that we’re concerned about overpayment, paying out
                money that we shouldn’t be paying and we’re trying to provide the
                information. We’re trying to following the guidelines that are set up and then,
                like I said, it seems like all the responsibility falls back to the provider to try
                to get it straight when Medicare or the group employer insurance just sits
                there and says, no, we’re primary. And then you end up having two carriers

Carlene Randolph:   Again, I would ask that you forward that comment to our box which
                would be M as in Medicare, F as in feedback, G as in group at
                and as soon as we get those questions in we will forward them to the
                appropriate member.

(Pam Tower):    Okay. Thank you.

Carlene Randolph:   Thank you. Last question?

Operator:       Your next question comes from (Cathy Aroseco).

                Your line is now open.
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(Cathy Aroseco): Thank you very much. My question, again, is about RAC. This recoupment
                 for these automatic reviews, is that going to be done by offset or a refund

Connie Leonard: Well, what happens on automated review is the provider will get a demand
                 letter - well, I’ll back up one step. The claim will be adjusted and the provider
                 will get the normal remittance advice just like you would on any other claim
                 and then the provider will get a demand letter from the RAC and then offset
                 does not happen until 41 days later.

                 So there’s a couple of different options for a provider. They could send the
                 check in. Providers sometimes do that because they want to avoid the interest
                 assessment that occurs on day 31. They can allow recoupment to occur which
                 will occur on day 41 which is from future Medicare payments.

                 Those are two primary ways that Medicare receives the money back from the

(Cathy Aroseco): Okay. So if we do allow the recoupment on the 41st day that would be an
                 offset of another patient, is that what you’re saying?

Connie Leonard: Correct.

(Cathy Aroseco): Okay.

Connie Leonard: On the 41st day Medicare will automatically recoup the money unless there’s
                 a valid appeal request in.

(Cathy Aroseco): Okay.
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Connie Leonard: The provide does not need to do anything in that case, it’s automatically set up
                  in the system to recoup the funds on day 41.

(Cathy Aroseco): Okay. So automatic reviews - we still have that 30 days to file the appeal?

Connie Leonard: Correct, you do and you still get notification from the remittance advice and
                  also from the demand letter from the RAC.

(Cathy Aroseco): Okay, thank you.

Carlene Randolph:     Okay. At this time we’re going to turn over to the last topic of the day, of
                  the Medicare Contracting Reform, Lessons Learned from Medicare’s
                  Administrator Contractor Implementation.

                  Karen Jackson, Director of the Medicare Contractor Management Group will
                  lead this presentation.

Karen Jackson:    Well, I hope that the slides that we made available for this presentation are
                  visible and that folks on the phone have been able to take a look at them. I say
                  that because I’m not going to spend any time on the slides.

                  What we wanted to do today, the slides really serve as background
                  information for you to talk about both the status of the Medicare Contracting
                  Reform initiative and to elicit feedback from you all about any kind of
                  observations you have about our management of this very significant
                  restructuring our of claims operations environment. And also to talk a little bit
                  about what we’ve done in response to feedback that we’ve already gotten.
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Just to refresh those memories CMS was required to employ full and open
competition for the competitive selection claims administration contractors as
a result of provisions in the Medicare Modernization Act of 2003.

Historically we have contracted with entities called fiscal intermediaries and
carriers for claims administration services including enrollment of providers
into the program, medical review and utilization analysis benefit payment.
They have historically done a very good job of acting as CMS’s agents in the
adjudication of the Fee-For-Service claim.

And what we began to do in 2003 with the passage of the Medicare
Modernization Act was an initiative that’s taken a little bit longer than we had
contemplated that it would take and is still underway in terms of it’s first
phases of implementation. And that is taking all of the claims administration
workload that has been managed by carriers and intermediaries and moving
that into contract entities called Medicare Administrative Contractors.

And with that movement we have done a significant amount of restructuring
of the jurisdictions of responsibility for each of the Medicare Administrative
Contractors long history in the operation of the Medicare program in terms of
state based fiscal intermediaries and carriers consolidating into large, not
necessarily geographically contiguous carries and intermediaries.

And now what we are doing for a number of reasons is consolidating all of
that into 15 A, B processing regions geographically contiguous combining the
administration of fiscal intermediary and carrier processing into a single entity
called the Medicare Administrative Contractor.
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We have a legislative completion date of the contracting reform
implementation to the extent of their being no more fiscal intermediaries and
carriers processing Medicare claims of October 1, 2011.

CMS had made its implementation plans to be able to implement significantly
before that. In fact, we had expected to have all of the acquisitions complete,
which we have. And all of the implementations complete by about now,
maybe a few months from now, but we have had to make some fairly
significant revisions to our implementation strategy because of the number of
protests that we’ve had on contract awards.

In the slides that we made available for this presentation we gave to you
information about the MAC jurisdictions as well as where CMS is in the
completion of implementation of the contracting reform provisions.

And what you should have in your packet is a depiction of the 15 A, B MAC
jurisdiction, four DME MAC jurisdictions and then there is a third set of
information about those MAC jurisdictions that are fully implemented and
then those MAC jurisdictions that are still awaiting implementation because of
corrective action on various contract awards.

What you’ll see is that we have of the 15 A, B MAC jurisdictions nine of
those jurisdictions are fully implemented. We do not have any MAC
jurisdictions in implementation at this time.

The most recent completion was jurisdiction ten which includes the states of
Alabama, Georgia and Tennessee and we completed that implementation a
couple of months ago and now we are completing the corrective action on the
remaining six jurisdictions.
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Those are jurisdictions to 6, 7, 8, 11 and 15. We hope to have those corrective
actions complete sometime early next calendar year and then we’ll implement
those contracts as we are able.

We still do expect to have the implementation of the contracting reform
provisions in the (MMA) completed by the legislative deadline and we are
currently in the process of getting ready to issue our request for proposals for
the re-solicitation of the durable medical equipment Medicare Administrative

These contracts are one year contracts with four option years and it’s sort of
hard for me to imagine but we’re in the fourth option year and a couple of
these contracts, or will be very soon, and so we need to be ready to go through
another round of competitions.

We’ve experienced a great deal of - or we have learned a lot of lessons as we
have implemented these contracts. And I think that with the good feedback
and some not so good feedback that we’ve gotten from providers and billers
have made some fairly significant changes to the way in which we approach
implementation so that the most recent implementations have certainly gone
much, much more smoothly than some of the earlier implementations.

Some of the early implementations where complicated by the National
Provider Identifier Implementation. There were significant changes to our
claims processing operational systems at the same time as we were
consolidating operational jurisdictions from a claims administrations
perspective and CMS has recognized and acknowledged and apologized in
multiple venues for some of the processing disruptions that providers
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The things that we have been focusing on in the most recent implementations
has been making sure that EFT agreements are finished prior to the cutover of
the new contract in the given state. As much early boarding as possible as we
can do for EDI claims submitters to make sure that changes that cutover the
new contract do not cause significant payment disruptions or disruptions in
the ability to submit claims.

I would comment that there are some responsibilities that providers and EDI
vendors have in terms of testing with the Medicare Administrative Contractors
and making sure that connections work well at the time of cutover or before
cutover. And as many different ways as we have tried to get out to the
provider community and pending cutovers we haven’t gotten to everybody.

And in some instances that has caused delays in payment.

What I had hoped to be able to hear from the participants on today’s provider
feedback group meeting where any observations that you individually have
about the way in which the agency has approached this implementation or
other operational implementations so that we can incorporate those into our
future implementation plans. And also to let you know that we will be putting
up for bid the claims administration contractors, again, at the completion of
the five-year performance cycle of these contracts.

So, we have a lot of opportunities to get much better at this with each one of
these that we do and we look forward to continued feedback from the provider

I will stop there and solicit input from the participants on the call or in the
room and I thank you for your time today.
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Carlene Randolph:    We’ll now open the floor to comments or questions.

                 Are there any questions or comments on the line?

Operator:        You have a question from (Brian Ernest).

                 Your line is now open.

(Karen Brown):   Good afternoon. This is (Karen Brown). I’d actually like to redirect this
                 question back to Connie Leonard’ regarding the RAC communication and the
                 use of the N469 versus the N432 and how that - the subsequent remits are
                 going to demonstrate the recoupment of the automatic denials?

Connie Leonard: And again, in the demonstration project we had the remittance advice from
                 code N432 and it was successfully used.

                 Unfortunately when CMS implemented the limitation of recoupment
                 provisions which allowed for the recoupment in the first two levels of an
                 appeal. They treated another code, N469 and (RAS) claims, as you all know,
                 are subject to the limitation of recoupment and currently in the system the
                 N469 is superseding the N432.

                 So claims that are being adjusted now are only seen in the N469. We are
                 working with our systems to correct that issue so that providers will see N432
                 as well as any other of the applicable remark codes.

                 We don’t think N432 should be used by itself. There are other remark codes
                 that tell why the claim was actually adjusted so that’s for providers. In the
                 meantime it’s going to be the demand letter that they’re going to be getting
                 from the provider, not the provider I’m sorry, from the RAC.
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                  It will include all of the applicable beneficiary as well as client information
                  and even the accounts receivable number that’s used by the claim processing
                  contractor so that demand letter is going to be used right now and then as of
                  January 1, 2010 all of the RACs have to have a claim status Web site. These
                  providers will also be able to go into to find out the status of some of their
                  RAC claims.

(Karen Brown):    Connie thank you for that. So once we have received a letter, an initial letter
                  identifying the claims and the remit comes with those offsets we’re going to
                  get a second letter which is the demand letter that you’re talking about?

Connie Leonard: What happens is when you first get that remittance advice the offset has
                  actually not occurred yet. I know that sometimes those remittance advices are
                  very confusing and I’ve actually seen some myself and it does appear that the
                  monies actually have been taken but they have not been taken.

                  So what will happen is you’ll get the remittance advice and the demand letter
                  and 41 days down the road the offset will occur.

                  Right now there is no use of the remark code in N432 or any other code at the
                  time of recoupment. I know that some of the hospital associations are working
                  with CMS to try to come up with the methodology to at least allow the claim
                  to show up on the remittance advice. They can also work it to a remark code
                  on their - I think this is still up in the air.

                  This is a relatively new issue that CMS has began working with with the
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                  So if you certainly have any ideas I would - we would appreciate your
                  feedback and sent it into the mailbox because we’re certainly cognizant that
                  providers want to be able to reconcile what they’re getting from the RAC with
                  what they’re getting on the remittance advices from the processing

(Karen Brown):    Thank you.

Carlene Randolph:     Yes operator, are there any other comments or questions on the line?

Operator:         You have a question from (Lisa Furena).

                  Your line is now open.

(Lisa Furena):    Hi this is (Lisa Furena) with (Emit) Medical Center. We are a rural health
                  clinic and we went through that MAC conversion as part of the J10 but we’re
                  really jurisdiction 2 and I was wondering if there was a location that I can
                  write or a Web site where I can log some feedback about our implementation

Christine Stahlecker: Yes ma’am. You can actually send it to the mailbox that I’ve been
                  mentioning throughout the session. It’s going to be M as in Medicare, F as in
                  feedback, G as in group at

                  Thank you.

(Lisa Furena):    Okay, thank you.

Carlene Randolph:     Operator, are there any other comments or questions on the line?
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Operator:         You have a question from (Jack Bradley).

                  Your line is now open.

Carlene Randolph:    Thank you.

(Jack Bradley):   Hi, Connie, I just wanted to ask, what was the percent of the overturn appeal
                  to those cases that where overturned when they go to the federal law judge?
                  What percent did you say?

Connie Leonard: The only percent that I had mentioned was in the August 2008 update to the
                  (unintelligible) in the demonstration. The overall appeal rate which is at all
                  levels is under 10%. In fact, it’s right around 7 or 8%. I also mentioned that
                  we are going to be releasing by the end of the calendar year another update
                  which will include percentages at the various levels of appeal as well as

(Jack Bradley):   And you mentioned something about those that not only with the RAC on it
                  but the Medicare audits are very similar percent when they go to the
                  administrative law judge or the federal courts. There’s a percent that was

Connie Leonard: Well, I think I was pointing out the caller had mentioned a 95% overturn rate.
                  And - not so much now, but historically from any improper payment
                  perspective, not just the RAC, that the levels of reversal rates as it gets higher
                  up to the administrative rule judge are higher but I don’t know any percentage
                  from a RAC or a regular Medicare contractor perspective.

(Jack Bradley):   Okay. I thought his point was very good in the sense of someone going
                  through this it affects their whole life, their business, their money. And when
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                  they’re unjustly targeted and there’s not fraud or there’s not abuse and it’s
                  overturned but it affects their whole life and their business and he’s wondering
                  what kind of recourse should there be for people that affect someone’s life
                  that way?

Connie Leonard: Well, as I mentioned the RACs are held accountable for those overturned
                  appeals and they do have to return their contingency fees and CMS has put the
                  safeguards in place to make sure that the RACs are making accurate and
                  proper payments. And that’s something I dint even talk about but we also have
                  medical record requests from this, again, trying to limit the administrative
                  burden that’s placed on providers.

                  So we certainly are always open to other feedback if providers have additional
                  ideas that CMS considers to lesson the provider feedback, provider burden
                  placed on by any audit not just recovery auditors.

(Jack Bradley):   Okay. Thanks. What was that Web site if we wanted to send information to
                  CMS or a question?

Carlene Randolph:    That email address, again, is M as in Medicare, F as in feedback, G as in
                  group at

(Jack Bradley):   Okay, thank you.

Carlene Randolph:    You’re welcome.

                  Are there any other questions or comments?

Operator:         You do have a question from (Nancy Horn).
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                  Your line is now open.

(Nancy Horn):     Actually, my question was already answered in a previous question so I’m
                  sorry to have wasted your time.

Carlene Randolph:    That’s okay. Can we move to the next question operator?

Operator:         The next question is from (Maurine Fox).

                  Your line is now open. Ms. (Fox), your line is now open.

                  Your next question comes from (Barbara Jump).

                  Your line is now open.

(Barbara Jump): I think you touched briefly on my question but the RAC have a (three-year)
                  looked at period and as far as I know the Medicare Fee-For-Service audits that
                  take place outside of RAC there’s no limit on audit look backs. Is there any
                  consideration or thoughts towards making a common look back for all audits?

Connie Leonard: That’s an idea that you can submit to the email box and we will have the judge
                  whether there is components in CMS.

                  But we did place a limit on the RACs because we’ve been very cognizant of
                  the burden that you can’t have providers because of the feedback we heard
                  from providers regarding the use of the contingency fee.

                  Other Medicare contractors are paid on a cost basis and there isn’t that
                  perspective that they’re just identifying payments to make money. Certainly
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                  some of our contractors such as the program contractors are our (thought)
                  entities that there certainly could not be a limit for those types of reviews.

                  But if you’d like to submit that question we can certainly post it to the
                  appropriate group for consideration.

(Barbara Jump): Okay. We’re having a lot of audit requests from the Medicare Advantage
                  Group and, of course, they’re using the same criteria that Medicare uses which
                  is no limit on the look back period so that’s why I was looking for some kind
                  of consideration along those lines.

Connie Leonard: We will certainly pass those comments along, thank you.

(Barbara Jump): Thank you.

Carlene Randolph:     Thank you. Unfortunately we do have a time constraint. I will take the last
                  question here from the audience.

Woman:            Connie it’s for you obviously. I’m on multiple list serves with practice
                  administrators nationwide and there’s been several comments made in regards
                  to whether or not it’s up to us as the provider to register with our RACs or if
                  RACs would reach to us or if we can just hang out and wait and we should be

                  What is the process defined as the CMS RAC rather than the individual?

Connie Leonard: The best thing for providers to do is to reach out and contact the RAC. Some
                  of the RACs actually have the format on their Web site and they’ll allow
                  providers to fax it in. Others actually have a Web base so that some providers
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                  can enter in their contact information. But we always tell providers to be
                  proactive, reach out and contact the RAC and set up that point of contact.

                  I know that there are some RACs who don’t have - they’re not looking from
                  the Part B perspective, for example, and I know that when some physicians
                  have called in the Region B RAC, the Region B RAC says, wait, we’re not
                  ready yet. We’ll contact you when we’re ready. But we always tell providers
                  to be proactive and go in and contact the RAC because that point of contact is
                  so important.

Woman:            That doesn’t make us any more concerning or if we don’t...

Connie Leonard: Oh, absolutely not. No.

Woman:            ...obviously that’s our greatest concern.

Connie Leonard: No, absolutely not. And I always try to explain - I know it’s a different
                  concept because it’s not how other Medicare contractors review claims but the
                  RACs aren’t looking at providers specifically. They’re looking at HCPCS
                  codes (DRG) across the board so when the review claims data they’re not
                  looking at the provider. So by provider calling up and giving a point of
                  contact it’s not going to single themselves out.

Woman:            And one other thing, you were stating that CMS will review the issues and
                  make them whether or not - what leads the issues to even come to the table in
                  the first place to be reviewed?

Connie Leonard: The RACs get ideas from the (unintelligible) reports and from the (OID).
                  They also get referrals from CMS if we’ve done any data analysis and we
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                   actually have a division that just does data analysis and they get ideas from the
                   program state contractors to identify a particular issue.

                   And then it’s just their own expertise, what they’re seeing in their commercial
                   contracts because most of the RACs do healthcare outside of Medicare
                   healthcare audit.

                   So, they get them from a wide variety of sources but, again, they do have to
                   comply with the Medicare rules and regulations.

Woman:             Thank you.

Connie Leonard: Thank you.

Carlene Randolph:     Yes, thank you. I’d like to introduce (Robin Fritter), the Director for the
                   Division of Provider Relations and Evaluations.

(Robin Fritter):   Thank you Carlene. Hello everyone. I’m responsible for the people who work
                   very hard to pull together today’s town hall meeting and I would like to thank
                   everyone for a job well done.

                   Especially I would like to thank everyone who participated in the program
                   today. For those of you who are in the audience and for those of you on the
                   line, we appreciate your time and the feedback that you have provided to us.
                   And we’d like to reiterate that by your participation today we - you are
                   automatically sort of enrolled in our Medicare feedback group email list and
                   we use you as a member of this list in a variety of ways throughout the year.
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Hopefully some of you have received questions from us throughout the past
year. If you haven’t hoping that you will be receiving those questions in the
future if you’re new as part of the feedback versus yourselves.

And we use the feedback that you provide to us in a variety of ways,
oftentimes using it to develop new educational materials, update educational
materials that already exist, developing FAQs, frequently asked questions that
we post on the CMS Web site, developing content that we post on the Web
site and certainly sharing the information with our regional offices, our
contractors and the many people in the variety of components who have
shared in the program today.

One important Web site I would like to share with you as we close is the sort
of central location for all of the Medicare learning network educational
materials and that Web site is s - let me just say it
completely and then I’ll spell it out for you, mlnjeninfo.

So that’s M as in Medicare, L as in learning, N as in network, Jen info, all one

On this Web site you can find - this is your sort of access to all of the
educational materials, products and services that we do provide direct from
the agency.

Another example of what you can do from this particular site is to join any of
the provider specific list serves which would ensure that you received up-to-
date information specific to your provider or type of provider area of interest.
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                I wanted to reiterate that the responses to today’s questions will be shared
                with everyone who is a part of the MSG email list so you will be provided
                with information that was shared with everyone verbally on today’s call.

                And anytime - I would just like to encourage that any time anyone of you has
                information, feedback, suggestions that you think would be of help to the
                provider community, we would encourage that you submit those ideas via that
                MSG feedback group.

                Because we’re the communications folks both internally and externally and
                we will do our very best to get answers to the questions and provide
                information and materials to help you better navigate the Medicare program.

                If there are no other questions or comments from our participants today I’d
                like to, again, thank everyone for your participation and wish you all well on
                your travels home.

Carlene Randolph:   Thank you. That concludes today’s meeting. If any of you have any
                questions or comments with you here in the audience you can certainly write
                those on the forms that are in your folders and put them out on the exhibit
                table or give it to one of the meeting facilitators.

                Thanks again and we appreciate your attendance and your participation.

Operator:       This concludes today’s conference call. You may now disconnect.

Carlene Randolph:   Operator, how many are on the line now, in total?

Operator:       At your highest point you had roughly 580. Five hundred and eighty people.
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Carlene Randolph:   Okay, thank you.

Operator:       You’re welcome.


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