AGENDA - Region D Advisory Committee - DAC - Region D ...



Region D DAC Combined Meeting Minutes

|Committee: Region D DAC Combined Quarterly Meeting |Time called to order: |

|Date: 03.01.16 |Time adjourned: |

|Members Present: Attendee List Attached to the Minutes |Location: In Person Mandalay Bay Convention Center Las Vegas,|

| |NV. |

|Contractor Attendees: |Chairperson: Gilbert Herrera |

|NHS: Dr. Peter Gurk, Cindy White, Tia Hastings-Rowe, Dr. Barbara O’Neal (telephone) |Recorder: Barb Stockert, Administration |

|CEDI: Stacy McDonald and Sally Hopkins | |

|CBIC: Elaine Hensley | |

|CMS: Laurie Tan (telephone) | |

|C2C: Daniel Roach | |

|Jurisd. C: Michael Hanna | |

|Purpose: Quarterly Meeting Update | |

| |RECOMMENDATIONS |

|AGENDA ITEM |OR ACTIONS |

|General Business |Gilbert Herrera reviewed the meeting protocol. Roll Call of the Executive Committee, A Team Leaders, and State |

| |Reps was completed. A list of the attendees is attached to these minutes. |

| |Gilbert presented a special thank you to VGM for the rooms. He also explained that a conference line has been |

| |set up for members and Contractors to call in on. This number was made available to all attendees. |

|Review of January 21st, 2016 Meeting Minutes |Rich Pozesky made a motion to approve them and Sheila Roberson seconded it. The minutes were approved. |

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

| |Paula Koenig asked if suppliers would have to re-enroll with the change in the Jurisdiction Contractors. Stacy |

| |explained that they are not anticipating any changes, so Suppliers will not be required to submit new |

| |documentation. Suppliers are currently set up in all four MAC’s the same. |

| CBIC Update |Elaine Hensley provided the CBIC Update. |

| |Round 1 is on schedule to begin the winter of 2017. She told everyone that the issues with the AO’s and BAO’s |

| |have been resolved for the most part. There are still a few issues in getting some registered so if you are |

| |having this problem please call the call center. The pre-bid evaluation has been done. If you didn’t have all |

| |your information on file you should have received a notice. The contractors review all the documents to be sure |

| |they have all the required documents. This also includes that financial information that is required. |

| |Round 2 and Recompete is moving along. The problems seen here are with CPAP, O2, and Diabetic Suppliers. This|

| |all goes back to documentation issues and will hopefully be resolved soon. |

| |Mary Stoner asked about the data suppliers are seeing when registering in Connexion. Elaine said that she would|

| |check and see why this is not matching up. She will check with the NSC and report back. |

| |Kimberlie Rogers-Bowers asked about the cpap transition and the volumes of patients that are trying to get |

| |supplies but there is no documentation from the previous suppliers that they are compliant. This documentation |

| |is impossible to get and suppliers have to turn many of them away. This means that many patients are going |

| |without their needed supplies. Elaine explained that they continue to bring this to CMS as a high priority. |

| |She is aware that there was a meeting last week on how to address these issues and now patient owned equipment. |

| |She will follow up with them but is not optimistic their project team will respond with a process for suppliers |

| |to use. |

| |Mary Stoner explained that this has been an ongoing issue since CB began. Is there someone at CMS to reach out |

| |to? Elaine said that Michael Keen and Joel Kaiser are their contracts or possibly Lawrence Wilson as the |

| |director. |

| |Connexion is not up and running yet, but it is most important for all suppliers to register if they want to |

| |participate in the Competitive Bidding Program. The first item that will be seen there is the contract offer. |

| |This is a separate portal that is available on their website that is accessed by a specific login and password |

| |for each supplier. Disqualification letters will go out after the contracts have been accepted. This is so |

| |they can see what kind of offers and response they get. |

| |There is not a hard, rigid deadline to sign up for Connexion. The CBIC encourages suppliers to get registered |

| |now because there is a 10 day window to accept or decline a contract. |

| |Paula Koenig asked about Connexion and what it is being used for. It is used for bid offers and will eventually|

| |contain the forms and documents that are needed such as subcontracting agreements etc. This will all be |

| |available. This is driven by the information that is available in PECOS and allows for one AO and one BAO. |

| |PECOS allows for multiple AO’s but D Bids does not. Elaine said she will check on this. She said the person |

| |who signs off on the bid must be an Authorized Official (AO). Since Connexion only takes one person to |

| |register, this does not have to be the person that signed off on the bid. |

| |Paula Koenig inquired about the Round 2 Recompete and said that wheelchairs are now paying correctly. When |

| |repairs are done and the RB modifier is used there are still issues. Paula asked if there was an update to |

| |this. Cindy said she has not seen one yet. |

|C2C Innovative Solutions |Dan Roach presented the C2C update. The Medical Director for C2C and this program is Dr. Janet Lawrence. Dan |

| |stated the QIC is most commonly known as the DME for the 2nd level of appeals. They take their work very |

| |seriously and their corporate value and mission are to provide a service of high integrity and service. He |

| |introduced Virginia Carraher, Peggy Skaplen, and Emily Stroupe as other C2C staff who were present. Emily’s |

| |position is Provider Outreach. Peggy’s is Policy and Medical. Virginia’s is Medical and Non-Medical Review. |

| |They will also be available throughout Med Trade to answer any and all questions members have. |

| |CMS has made a change in the appeal process so they are now allowing a formal telephone discussion at the 2nd |

| |level of appeal so the supplier can present verbal testimony an additional documentation in support of their |

| |claim. The demonstration project will be done throughout Jurisdiction C and D on O2 and diabetic supplies. They|

| |will invite suppliers who have received denied claims based on lack of documentation. It is the Supplier’s |

| |decision if they want to participate in this project but they are hoping that most suppliers will do this. This|

| |is also limited to a maximum of 5 claims per NPI and will be initiated by C2C. Their notification will be sent |

| |via mail and suppliers will have 14 days to respond. Once the contact form is completed and returned to C2C |

| |communication should be able to be done via electronic means. This will be particularly helpful for those who |

| |do not get their letters timely. |

| |CMS has also given C2C the ability to pull back claims that are at the ALJ. This is effective for dates of |

| |service 01/01/13 through present. If C2C feels a claim has the potential to be payable they will reach out to |

| |suppliers. The supplier will have 14 days to respond to their request. |

| |A separate email and phone number will be established for the demonstration project. |

| |C2C will be at the Noridian and CGA booth during the show. Please do not hesitate to stop and visit with them |

| |if you have questions. |

| |More complete information on this project is listed below and included in the link and also attached to the |

| |minutes. |

| |On January 01, 2016, CMS launched a new Demonstration with DME Suppliers that submit Medicare Fee-For-Service |

| |(FFS) claims, called the Formal Telephone Discussion Demonstration. The Demonstration will provide selected |

| |suppliers that have submitted second level appeal requests, called reconsiderations, the opportunity to |

| |participate in a formal recorded telephone discussion with the DME Qualified Independent Contractor (QIC), C2C |

| |Innovative Solutions, Inc. For more information on this demonstration, see the following link: |

| | |

| |The CMS Fact Sheet is also attached to the minutes for your convenience. |

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

|CMS |Laurie Tan from the CMS Seattle Office. Was present on the phone. She did not have an update to present, |

| |however Mary Stoner asked about her previous question on PECOS. Mary forwarded Laurie examples of PECOS denials|

| |after the last meeting but nothing more has been determined. Mary explained that we verify the physician is |

| |enrolled when we provide service but when the claim is submitted it denies because they are not enrolled. Mary |

| |further explained that this is the tool that CMS provided to Suppliers and if it does not work we should not be |

| |held responsible for it. The VMS System provides different information than the does. Another |

| |problem could be when a physician is registered in multiple states and the information is not registered in the |

| |VMS system. This can happen when a physician is active in one state but not others. Their status is not |

| |accurately reflected because the VMS system only shows that they are deactivated. |

| |Laurie responded that these are very valid points and asked for Mary to reconnect with her after the call so |

| |this can be further researched. |

|Jurisdiction C Update |Michael Hanna provided the update for CGS. It is estimated the timeline for Cigna to start the Jurisd. B |

| |Contract is July 1st. Roc Via is the program director for Jurisd. B. Currently he is in negotiations with the|

| |different state associations within Jurisd. B to help make the transition as smooth as possible. The following |

| |website can be accessed to gain information as it becomes available: . |

| |There will also be updates presented during the Medicare Update Session today at 4:00 pm in the Islander B room.|

|Medical Director Update |Dr. Gurk introduced himself and explained that he has now assumed Dr. Moynihan’s role. She will be focusing on |

| |Part B. Dr. Whitten has moved into an administrative position but is still involved with everyone. Dr. Gurk |

| |used to be with Health Data Insights but has been with Noridian for about a year. He lives in Las Vegas. |

| |Dr. O’Neal did not provide an update. |

| |Sheila Roberson asked about ventilators. Dr. Gurk said the medical directors are having on- going discussions |

| |on these. |

| |Dr. Gurk said the hot topic right now is IV Drugs and are under recurring discussion. |

| |Deanne Birch asked about a statement she heard regarding RAC Contractors and that as of Jan. 2016 the look back |

| |period would only be 6 months instead of 3 years. Dr. Gurk replied that he had not heard of any changes on this|

| |but that the awarding of any RAC Contracts is still on hold. |

| |Mary Stoner asked about the possibility of Medicare eliminating coverage on off the shelf prefabricated |

| |orthotics. Dr. Gurk has not heard anything. |

|POE Update |Cindy White presented the POE Update. This is attached to the minutes. |

| |Cindy also updated DAC members that the Medical Directors are a huge asset to the Education Team and are very, |

| |very helpful. |

|Yondelis and Blincyto |Deanne Birch asked the following question regarding the recent release |

| |of 2 Joint DME MAC publications released regarding coverage and coding |

| |for 2 new drugs, Yondelis and Blincyto™.  Could the Medical Directors |

| |provide some insight as to why it was determined that Blincyto |

| |administration via External Infusion pump would be covered and included |

| |under the EIP LCD benefit but Yondelis via External infusion pump was |

| |determined as NOT eligible for inclusion under the EIP LCD? |

| |01/21/16 Dr. Gurk replied that he will take this question back and provide an update in Las Vegas. |

| |03/01/16 Bill Noyes asked if Dr. Gurk could shed any light on the recent Joint Publication which denies payment|

| |via the DME benefit for Yondelis in the home. Dr. Gurk said that there has been much discussion amongst the |

| |DMD's and they are awaiting guidance form CMS regarding drug therapies that are initiated by a physician and |

| |then continued in the home. Bill stated that this was a challenge because Physician and HOPD's often do not |

| |have the means to support equipment and patients in the home 24/7 - that is what Home Infusion Providers |

| |specialize in. |

|Previously Submitted Questions to CMS/Noridian and|Billing for Purchase: We need assistance from CMS on a claim processing |

|CEDI |issue. Suppliers sometimes provide capped rental items to Medicare |

| |customers that are not medically necessary per Medicare coverage |

| |criteria. However, that item may be covered by Medicaid or another |

| |funding source, as a purchase. The secondary funding requires a denial |

| |from Medicare. Currently, any claim submitted for a capped rental item |

| |with a NU modifier will be rejected on the front end as an invalid |

| |code/modifier combination. This does not give an actual claim denial. Will |

| |CMS please issue claim processing instruction revisions to allow |

| |submission, and subsequent denial, for capped rental items provided and |

| |billed as purchases with NU modifiers? Examples of applicable situations |

| |can be provided. |

| |10/28/15 Update: Most often these companies require a Medicare denial to process and pay the claim. The way it |

| |is currently set up the claim cannot even get into the system. Discussion followed and this will be |

| |researched. It is possible something could be done or an edit added. |

| |01/21/16 Update: Cindy replied that there is not a solution for this. Mary Stoner asked if a modifier could be|

| |created or another means to identify claims in this situation. Cindy replied she will bring it back but because|

| |we are asking for a different pricing category they might not be able to do this. |

| |03/01/16 Update: Cindy replied that there is not a modifier for this to get a denial, and it is unlikely that |

| |one would be created to satisfy a secondary insurance requirement. She said she understands it would be |

| |advantageous for suppliers to have something established from a secondary to allow for this. Mary Stoner asked |

| |Laurie Tan (CMS) for her thoughts. Laurie responded that she was not aware there was not a modifier. She said |

| |there is one on the Part B side. She asked for Mary to send her the information after the call and she will |

| |have the Central Office look at it. |

|HyQvia Coverage Policy |HyQvia Coverage Policy: This was brought forth in Oct. 2015. The IV PEN team wanted to know when the HyQvia |

| |coverage would be added to the External Infusion Pump LCD. It was understood that there were numerous comments |

| |on this. Bill Noyes asked that this be added to the LCD. It is only seen in the joint publication. As a |

| |reminder: this was/is the concern noted: The issue is conflicting/contradictory language between with the EIP |

| |LCD and the HyQvia Joint publication. |

| |The EIP LCD states: H. Subcutaneous immune globulin (J1559, J1561, |

| |J1562, J1569) is covered only if criteria 1 and 2 are met: |

| |The subcutaneous immune globulin preparation is a pooled plasma |

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

| |The beneficiary has a diagnosis of primary immune deficiency disease |

| |(See Diagnosis Codes Group 3 that Support Medical Necessity section below). |

| |Coverage of subcutaneous immune globulin applies only to those |

| |products that are specifically labeled as subcutaneous administration |

| |products. Intravenous immune globulin products are not covered |

| |under this LCD. Only an E0779 infusion pump is covered for the |

| |administration of subcutaneous immune globulin. If a different pump |

| |is used, it will be denied as not reasonable and necessary. |

| |But the HyQvia (which is Subcutaneous IG) Joint Publication specifies |

| |the need to use an E0781 pump. |

| |  HYQVIA is administered using a programmable variable infusion pump |

| |(HCPCS code E0781), that is capable of infusing a patient’s |

| |therapeutic dose at infusion rates of up to 300 mL/hr/site. |

| |Coverage is available for claims with dates of service on or after |

| |September 12, 2014 when all of the following requirements have |

| |been met: |

| |The criteria for Subcutaneous Immune Globulin as specified in the |

| |External Infusion Pump LCD are met, and |

| | |

| |HYQVIA is administered subcutaneously through an E0781 |

| |pump that is pre-programmed, and |

| |The E0781 pump is delivered to the Medicare beneficiary in a “locked |

| |mode” i.e., the patient is unable to self-adjust the infusion rate. |

| |The medical record must contain sufficient information to clearly |

| |demonstrate that the beneficiary meets all of the requirements |

| |specified above. |

| | |

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

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

| | |

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

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

| |expect an answer sooner rather than later on this. They meet |

| |again next Tuesday so hopefully this can be put to rest then. |

| |03/01/16 Update: Bill Noyes asked Dr. Gurk that in the most recent all councils Q&As the DMD's indicated that |

| |they were looking at adding the HyQvia policy to the External Infusion Pump LCD. I asked when we could expect |

| |to see the updated LCD because providers are seeing denials, which I think is caused by the inconsistency |

| |between the current EIP LCD and the 7/30/2015 Joint Publication regarding HyQvia coverage. Dr. Gurk's reply was|

| |they are still working on this but an answer is expected this coming Thursday. |

| PECOS Denials |10/28/15 Numerous concerns were noted. Many physicians that are listed as PECOS certified on a date of service|

| |are not listed there when the claim is processed. Cindy clarified that it should be the date of service not the|

| |date of submission. Sheila Roberson said that Jody gave her some information that the information might not |

| |pick up when it is reactivated. Such as ½-12/31. Jody suggested to print screen each PECOS denial and send |

| |these in. Cindy asked that these now be submitted to her. Mary Stoner asked how does the Supplier know and |

| |how can we get claims to pay? She stated it should not be the patient’s responsibility to pay either. Cindy |

| |said we have to figure out the problem and then find the solution. DAC members are to submit issues to the DAC|

| |Office. They will be sent to Cindy. |

| |Paula Koenig asked about a situation when a Dr. is elgible when the order is written but they retire and give up|

| |their number, so the order would not be valid. The answer received was a joint answer from all the MAC’s. The|

| |will relook at this 13 months after implementation. |

| | |

| |01/21/16 Mary Stoner asked about PECOS Denials on claims which are |

| |denying because the Dr. is not enrolled in PECOS. When the Supplier |

| |checks the PECOS website it shows the Physician is enrolled, but when the claim is submitted it will deny |

| |because they are not enrolled. Mary said |

| |the information you are seeing on your side is not what we are seeing on |

| |our side. Laurie Tan CMS Representative requested for Mary to send her examples of where this has been an |

| |issue. She will look into it and send to Central enrollment staff. Mary will send these to her after the |

| |call. |

| |03/01/16 No Additional Update at this point but this is a continuing work in progress. |

| Issue with Orthotic Fitters |10/28/15 Joe McTernan, AOPA and O&P Team asked about requirements in the states for Orthotic Fitters. Since |

| |many of these regulations were written prior to states requiring licensing it could be a legal question. Dr. |

| |Whitten asked for some examples of specific states where there might be an issue. He expects that CMS will be |

| |actively involved in this. |

| | |

| |10/28/15 Update: Dr. Whitten asked for some examples of specific states where there might be an issue. He |

| |expects that CMS will be actively involved in this. |

| | |

| |01/05/16 Update: The examples requested did not get submitted to NHS. The DAC Office just received these today |

| |and am attaching with to this email. |

| | |

| |01/21/16 Update: Cindy responded that she had just recently received these examples but wanted clarification on|

| |what we were asking. Wendy Miller, O&P A Team Leader responded there are a few states that license orthotic |

| |fitters and they are allowed to fit prefabricated devices. She requested a better explanation of the rule and |

| |the requirements. Cindy will take this back for further discussion. |

| | |

| |Wendy Miller asked if there was an update. Cindy and Dr. Gurk replied that they had received the examples but |

| |would like clarification on what we were asking. Wendy explained currently there are 5 states that require |

| |licensure and that orthotic fitters are trained to modify and fit these when providing. A question was also |

| |asked about authorizing fitters to provide prefabricated orthotics. They are often better trained and have more|

| |expertise than an orthotist. A review by the Medical Directors on this would be greatly appreciated. Dr. Gurk |

| |agreed to re-present this for discussion. |

|Date of the Order and Start | Cindy White told members the standard documentation requirements for orders has been revised and has already |

|Date (03/01/16) |been added to some of the documentation requirements in the LCD’s. |

| |When the order date and the start date are different and the physician is writing the order, there only needs to|

| |be one date on the order and this can be the physician’s signature date. |

| |If the order is generated by the supplier then there must be two dates on it. |

| |Mary Stoner asked if this was a clarification or what the effective date would be. She stated that Suppliers |

| |have already received denials on this. Cindy replied that there was no effective date but the standard |

| |documentation language had been added to some of the policies. |

| |Deanne Birch asked about DIF’s and which date would be applicable. Cindy replied that the date of the order |

| |should be the date the physician signs it. If the order comes from a facility the signature date is |

| |acceptable. Currently Noridian is denying claims when the discharge date is used because there is not a start |

| |date listed on the discharge instructions. Cindy explained this would be a problem because there is no way for |

| |the carrier to know if there is no specific start date listed. They are not able to assume what the order |

| |date is. Cindy will check on this and report back. |

|HCPC Code Description | Sheila Roberson mentioned they are seeing claims deny because the entire HCPC code description is not included|

|(03/01/16 |on the invoice.( Ex: E0260 Semi electric hospital bed with mattress and full length rails). Cindy said she |

| |would check on this too. |

| New Questions to Noridian | 01/21/16 Can an update be provided to DAC members? Cindy explained that they have to wait for CMS direction |

|Prior Authorization |before any information can be released. She said the best option is to be sure members are signed up for the |

| |List Serv. |

| |Cindy Coy asked Laurie Tan if there has been any education done to |

| |referral sources? We need to be able to provide information to them. |

| |Laurie asked that Cindy email her this and she will try to respond. |

| |03/01/16 Update: No update was given. Members were encouraged |

| |to watch the list serv as they will find out the same way the Carriers |

| |are instructed to. |

|Capped Rental Motors and Controllers (03/01/16) | The following concern was presented. Now that motors and controllers are considered a capped rental there |

| |are no suppliers who are willing to do repairs. The manufacturer offers a 90 day warranty so repairs will not |

| |be covered and the supplier will have to absorb the cost. The warranty period was not considered when the CR |

| |was written and the language decided. The Executive Committee asked for direction on this and who they could |

| |work through. Noridian suggested that Joel Kaiser at CMS would be the best resource. |

| Update on SMRC Activity | 10/28/15 Can we get an update on SMRC activity? Kimberlie Rogers-Bowers explained that you do a great job |

| |educating and working with the CERT contractor to keep everyone aligned with the same processes in looking at |

| |documentation. It is our hopes that this will be the same way. Cindy replied that this is a different |

| |contractor and they operate separately from Noridian. |

| |01/21/16 Update: Barb Stockert asked if they would be able to provide a contact name with Strategic Health Care|

| |so we could invite them to our meeting in Las Vegas. Noridian will check into this and if able provide the DAC |

| |this information. |

| |03/01/16 Gilbert thanked Cindy White, with Noridian as she was instrumental in contacting SMRC to review our |

| |questions and issue a response. |

| |Members from all Councils were alerted to this opportunity and questions were gathered and submitted last week |

| |to SMRC. They will respond to these as soon as possible. |

| |Barb reported that they had been invited to the meeting either in person or by teleconference but they had |

| |declined. As soon as the responses are received Barb will send these out. |

|TeleHealth Medicine |01/21/16 Mary Stoner presented: Telehealth Medicine is becoming more and more prevalent. Are there any |

| |products or product categories that would not be acceptable for telehealth orders? Example...orthotics...can a |

| |telehealth doctor that has never "seen" only "has spoken" to the patient order a brace? CMS has a number of |

| |publications regarding this but they are not real clear. Cindy said she will take this back to the POE |

| |Committee and see if training can be done in this area. |

| |03/01/16 Update. Cindy said this is on her long to do list and should perhaps move it up. Mary re-explained |

| |her concern. She has a patient in Iowa that sees a physician through telehealth in California. This physician |

| |is part of a global telehealth medical group. When asking for physician documentation or medical records there |

| |are none available from the patient’s primary physician because the patient is being seen through Telehealth not|

| |his regular physician. What options do suppliers have and what are the rules regarding this. |

| |A lengthy discussion followed. This will be further researched and an update provided in the future. Telehealth|

| |is governed by state laws and have to follow the rules if Medicare is paying for these visits. Wayne Van Halen |

| |explained that many of these visits are paid through the beneficiary’s Health Savings Account. Cindy said that |

| |CMS has specific guidelines on this and state rules have to be followed. She will research further and provide |

| |an update at the next meeting. |

|Transition to JA Contract |01/21/16 Is this going to be handled in the same location/office that our JD contract is? Is it the intention |

| |of CMS/Noridian to eventually make this a Combined Council? Cindy responded that there will be contact |

| |information released soon on this. Currently the one area they are considering is to have a shared List Serv. |

| |She emphasized that JD Suppliers would see no impact with this transition. She will provide more information as|

| |it becomes available. |

| |03/01/16 Update: More information will be released in the future. Watch the list serv and check out the |

| |Noridian website for information as it becomes available. |

|Modifier Use with the 2016 Fee Schedule Changes |Paula Koenig asked if there is an update or any changes to the modifier use with the 2016 fee schedule changes? |

| |Most particularly using the KE and KY modifiers? Also, is there an update on the exclusion of applying the |

| |RSPA’s to wheelchair options used with Group 2 power chairs? There is not an update at this time. They will |

| |notify us when this becomes available. |

|Pick up and Redelivering of Equipment |Kim Brummett ask to clarify the following: A supplier is not required to pick up and redeliver equipment. A |

| |supplier is to get a new WOPD and proof of delivery, or attestation statement, but they do not pick up and |

| |redeliver. Can Noridian please look at this and revise this education because they are currently the only MAC |

| |instructing this process? Cindy replied they practice the way they interpret the rule but will take it back and|

| |relook at it. Kim said that an attestation statement should be allowed and can present their concern to CMS and|

| |ask for clarification from them. |

|Next Meeting |The next Meeting is set for Thursday, August 11th from 2:00-3:30 pm CST. This will be a teleconference |

| |meeting. |

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