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2006 March Minutes - DAC


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									                     Region D DAC/CIGNA DMERC/IntegriGuard/EDS
                                    Meeting Minutes
                                     March 22, 2006
                         Las Vegas Convention Center, Room N262
                                      9:00 am PST

Region D DAC Executive Committee Members: Chair: Val Taylor; Secretary: Rick Graver;
Treasurer: Reid Bellis; and Past Chair: Rich Pozesky. Administration: Rose Schafhauser.

CIGNA Government Services/Region D DMERC: Doug Frazier, and Kathy Brock.
IntegriGuard/EDS: Dr. Mark Pilley, and Missy Edison, Policy Coordinator.

Region D DAC Participants: see enclosed listing.

Meeting opened at 9:01 am

                             1. Introductions of all attendees ensued.

                                    2. General Business:
      a. Review of meeting protocols: Chair Val Taylor reviewed the meeting protocols.
b. Approval of meeting minutes: A motion to approve the October 18, 2005 meeting minutes as
          written by Sharon Nichelson. Second by Laura McIlvane. Motion carried.

                                  3. Medical Director: Dr. Mark Pilley:
   a. Dr. Pilley expressed that he appreciates the opportunity to work with the DAC. He plans to
continue on with the interaction with the DAC and to keep an open line of communication. Their
           objective is to pay claims right and appropriate and be available to the industry.
b. Nebulizer policy will be released sometime next week for notice and comment. They will have
 open forums. The dates of the forum have not been set, but should be late April. The forum will
 most likely be in the Kansas City area and should have a teleconference option. The deadline to
     comment will be in May. Comments will be accepted through the following email address:
                                   draftlcdfeedback@integriguard.org .
    i. Dr. Pilley recommended the DAC member’s sign up for list serve under DME Home Page
   http://www.edssafeguardservices.eds-gov.com/providers/dme/listserv.asp . The policy will be
                                      released through the list serve.
       c. Make sure to also visit the Program Safeguard Contractor (PSC) website by going to
                            http://www.edssafeguardservices.eds-gov.com .
 d. Alphanumeric group is busy working on coding and medical review on claims. They do data
 analysis on claims for any issues and opportunities for education. Discussed the Comprehensive
 Error Rate Testing (CERT) program. There are different types of error rates on claims. They do
data analysis of trends for product sales. Their objectives are to educate through this process. The
CMS Document Center (CDC), an electronic data base, will be sending letters for documentation
                       of further information. This is part of Program Integrity.
  i. Challenges may exist between the Medicare Administrative Contractor (MAC) and the PSC.
                             Both entities are committed to make it work.
ii. Region D DAC Chair Val Taylor introduced the concept of the new transition team, formally
           the ADHOC committee that will work together with the respective entities.

   4. Medicare Beneficiary Information – Provider Access: Rick Graver provided background
information regarding the issue on the same/similar denials. The goal was to identify better ways
    to address this issue. The DAC developed a white paper on a more efficient way to verify
    same/similar equipment for the beneficiary. Currently the only was to access the common
                      working file (CWF) is on a 3 way call with beneficiary.
   a. Dr. Pilley responded that there is no pre-certification except for the ADMC program for
     certain equipment. This is not an easy answer. He suggested sending the request through
 contractor and CMS. Doug Frazier sends the meeting minutes to CMS. This issue will continue
                                          to be addressed.

                      5. POE Update: Doug Frazier reported on the following:
 a. Spring Seminars are being conducted. The seminars are called "Medicare, a New Beginning".
  They will discuss the Medicare Contractor reform, claim submission, orders, medical records,
    modifier usage - KX modifier goes to adjustments, and changes to the appeals process. The
seminars start in April. CIGNA did not send mailers, so only online registration is available. You
                 are now able to pay with a credit card. The DAC is invited to talk.
                                       b. Webinars are on hold.
                     c. Net Courses: now up to 25 courses. New one on CMNs.
  d. CR4376 Suppression of Standard Paper Remittance Advice to Providers and Suppliers Also
   Receiving Electronic Remittance Advice for 45 Days or More: As of June 1, 2006 remittance
   advices will only be electronic, and will no longer get paper. This will be effective for billing
  services as well. CMS is going away from paper. CIGNA has rolled in a Net Course on Remit
     Software program. Brochures are available. Electronics Funds transfer may be mandatory.
  e. With uncertainty in the future of who will be the DME MAC, Doug Frazier indicated that as
       an organization, the Region D DAC needs to stay strong. He thanked everyone for the
                        opportunity to work together. It has been a pleasure.

                                          6. New Business:
     a. Flow of information. Sharon Nichelson reported that the Region D DAC Orthotics and
Prosthetics A-Team had worked on pricing for L codes that were created for PT/OT codes. They
         had worked with Barbara Douglas and CIGNA. She is not sure of the status of it.
 i. Response: Dr. Pilley recalled seeing something on this. He is not aware of the status and will
                           find out. He meets frequently with the group.
  b. CPAP LCD/NCD: (LCD ID NUMBER L171 issued 3/1/06) Joe McKnight reported on the
 discrepancy on minimum requirements for sleep study - specifically, the change in language in
  the appendices that indicates that the AHI is determined by 2 hours of sleep time rather than 2
 hours of recording time as printed in the previous LCD's. Moreover, the latest version of L171
notes in the "other comments" section that "Revised the definition of AHI to require a minimum
of two hours of recording time without use of the device rather than 2 hours of sleep time". The
question is how to eliminate the confusion that exists within the LCD and why was the language
i. Response: Dr. Pilley responded that it should reflect NCD. The LCD is written based on NCD
and is used to further explain the NCD. The language in the NCD requires 2 hours of sleep. The
LCD has 2 hours of required sleep time. Dr. Pilley will bring this up for further discussion. The
LCD has to reflect NCD. 2 hours of recorded time does not exist - it is 2 hours of recorded sleep
 time. Dr. Pilley stated that he didn't see any difference between sleep time and recording time.
   Question of Dr. Pilley if this may change? He responded that he will discuss with the other
    entities and will provide clarification in some form. The DAC also requested to share this
                                   clarification with sleep doctors.
 c. White Paper on BIPAP ST change in payment category: The DAC has written a white paper
     on this issue that we would like to have reviewed and will be sent to CMS, and the PSC.

                                            7. A-Team Leaders:
                              a. EDI/EMC: There were no further questions.
                b. Education/Communication/PCOM: There were no further questions.
                                                  c. HME:
    i. Question # 3: A-Team Leader Barb Stockert asked that on written orders to please clarify
                                "electronic" written orders – is it an email?
     1. Response: Doug Frazier responded yes it is as long as it has all the requirements for the
  written order. CMS has not clarified the signature issue. As long as the signature is notated in
     patients file. Dr. Pilley added that when you get orders by email, this may be an un-secure
     communication – for it includes personal health information - and would be a violation of
            HIPAA. Fax and mail orders are the best. Be cautious about email processing.
                     a. Question: What if it was an encrypted email that is secure?
                    b. Response: Can't really answer. CMS has some issues with it.
  ii. Question # 4: Please re-explain first part of the answer in regards to the new supplier. Barb
   presented an example of a provider had billed in error, had done a pick-up, and refunded the
   money. Now the provider will be providing equipment again. The DMERC customer service
                                 representative told them how to handle it.
   1. Response: Doug Frazier indicated that an exception is if there is no one else to service the
 patient, this can be done. Make sure to document in your files that this is the case. However, the
     provider will not get paid for previous service. It would restart the clock for capped rental.
a. Barb asked where this would be documented in writing. Most of the team members understood
  the policy to read that if we provided an item that required a WOPD and we found out that we
       did not have this -- but before a claim was submitted. We could do a pick up, get a new
  prescription, and redeliver the item. We did not think that it had to be provided by a different
   supplier. What we wanted Doug to clarify was where in writing it stated that we could never
                                       provide and bill for this item?
b. Response: this is not in writing. Doug will check if there is something available to address this
                          d. Infusion Therapy: There were no further questions.
                                            e. Medical Supplies:
       i. Question # 9: Assistant A-Team Leader Mary Turner asked for further clarification in
 situations where the provider is not always aware the beneficiary is in a HHS/PPS episode even
                                    though they are asking the question.
1. Response: Doug Frazier responded that the provider can bill the HHS or SNF, and if they will
        not pay, can bill the patient. In early 2005 in a Change Request it was clarified that if a
 beneficiary is in a SNF PPS and you are providing services you have to get a written agreement
                                         to get paid from the SNF.
     a. Mary asked if the document exists between supplier and a HHS/SNF, how do we get that
                           b. Doug said at this time there is no way around this.
 c. Mary responded there used to be a form that could be used and was hoping for reinstatement.
                   d. Doug will research this and look as to why this was taken back.
                             i. Mary will do another white paper on this issue.
                           ii. Question # 9 - letter E: How do we go about this?
1. Response: Doug Frazier indicates there is not anything at this time and suggests including this
                                                in the white paper.
     iii. Question # 10: In regards to an ABN for same/similar, the term "genuinely" used in the
                                                response is vague.
1. Response: Most providers may have an idea, or if there is a question in your mind, make sure
                                                  to get an ABN.
                                   a. What documentation should be used?
        b. As long as the reason on ABN is sufficient to inform the consumer that they may be
        responsible. Something like "It is our belief that you have had this equipment before..."
   i. Mary responded that she will do a follow-up question in writing about being able to bill the
                                       patient if the SNF/HHS won't pay.
                       f. Orthotics & Prosthetics: There were no further questions.
                                                      g. Rehab:
  i. Question # 15: A-Team Leader Leslie Rigg indicated that providers are continually having a
     problem with the coding and matching the equipment. She acknowledges that this is under
                          discussion and looks forward to an additional response.
 1. Response: Dr. Pilley reported that Dr. Doran from the SADMERC is continually working on
 this. There will be a breakout on weights. It is in process to move forward and wrap this up, but
                                            he does not have a date.
                                                  h. Respiratory:
 i. Question # 16: A-Team Leader Yvonne Cordoza stated that providers understand the right to
request further documentation. However, they do not understand why the claim is suspended for
               so long to get information. Would like further explanation on the hold up.
    1. Response: Dr. Pilley responded in the case of nebulizer drugs, if the beneficiary needs the
  level of dosage that is more than allowed it goes to medical review for further documentation.
       a. Why can’t the DMERC pay the allowed amount and deny the rest, because it holds up
payment on the whole claim when it goes for development. Then the provider would review the
                additional dosage with the clinical documentation for the medical need.
    b. Response: Doug Frazier indicated that CMS changes edits all the time. He thinks that edit
                    changes are in place to stop these claims from being processed.
                                 i. Is there a way for a provider to stop this?
    ii. Response: Doug feels there is no way to stop this. He suggested it be a question for CMS.
               1. Dr. Pilley indicated they did not know and will follow-up on this issue.
ii. Question # 17: Request for clarification when a doctor is attesting the further need for oxygen
  because a beneficiary is unable to make it into the doctor’s office because they are bed ridden.
   1. Response: Dr Pilley said this is an issue in all regions. If you are provider, and you submit
   claims, in support of doing testing in the home. A home health nurse does the test; the results
 should be able to be used by the doctor. Doug Frazier clarified that if the test is able to billed, it
then could be used in the report. If the test is not able to be billed to Medicare, it will not be able
                                              to use the report.
iii. Question # 18: Received different responses on this. Need more clarification in regards to the
                                       test being done on same day.
    1. Response: Dr. Pilley reported that when a doctor is testing in their office, there should be
   oxygen in the office. However, this is not a requirement. When the beneficiary exercises and
   they desaturate, the payment should be justified. Blood gases takes precedent, but all doctors
  don't have it. It is written the way it should be performed. It is important to do the tests on the
                                                  same day.
                a. Nowhere is it written in the policy that it must be on the same day.
    b. Doug responded that when they have conducted training in seminars, they have received
 response from medical review that it needs to be on the same day. It is not in the policy and Dr.
                                Pilley states that it should be in the NCD.
     i. Other Issues: Are the ADMC and medical reviews going to the PSC/IntegriGuard? Had
                    received discrepancies that the PSC was not doing the ADMC.
   i. Response: This was an error in their communication. ADMC and medical review transfers
       from CIGNA on March 1. And if not determined by March 1, forwarded from CIGNA.

Region D DAC Participants

Asela Cuervo
Barb Stockert
Barbara Strong
Carlos Reyes
Cheryl Stokes
Chuck Gunther
Connie Lind-Fraher
David Bryant
Dawn Jorgensen (representing Laura Steelquist)
Deanne Birch
Diana Guth
Don Hardin
Dorene Alderetti
Evan Call
Gemma English
Gene Salisbury
Joe McKnight
Joseph Rolley
Kay Martin
KC Cooper
Kimberlie Rogers-Bowers
Laura McIlvane
Leslie Rigg
M. Edwards
Marshall Pollock
Mary Jackson
Mary Turner
Mike Hayden
Paul Kesselman, DPM
Reid Bellis
Rich Pozesky
Rick Graver
Rosalie Weber
Rose Schafhauser
Scott Alberts
Sha Eppley
Sharon Nichelson
Sheila Showalter
Sheila Ross
Steve Treinen
Tami Joplin
Teri Jamison
Troy Paz
Val Taylor
Velma Goertzen
Wade Hendrickson
Wally Tschopp
Yvonne Cordoza
Zena Jacobi

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