Provider Outreach and Education Advisory Group (POE AG) Meeting Minutes - June 13, 2023

Roll Call

POEAG Member or Other (CMS) Attendees

JE: Angela Amey, Cheryl Bradley, Mitchel Kaye, and Susan LaPadula

JF: Anna Gauslow, Carol Self, Dawn Davidson, Jana Weis, Lisa Davies, Mindy Gale, Mollie Brooks, and Susan Albaitis

Noridian Attendees

Teresa Cirelli, Cheryl Hanson, Dani Aasen, Jan Ervin, Tammy Ewers, Tim Morrissey, Val Cavett, Kathryn Grueneich, Jared Gibbon, and Julie Schroeder

POEAG Mission and Goals

The primary function of the POE Advisory Group is to assist Noridian in the creation, implementation and review of our provider education and training strategy and efforts. The input received from these groups will affect the way educational materials and correspondence are presented, the content contained in them and how Noridian can best provide resources for the provider community.

Prior Meeting Minutes

The prior meeting minutes were distributed to POEAG members and published to the website(s).

Prior POEAG Member Recommendations

Below are the POEAG member prior meeting recommendations and the progress or resolution for each item.

  1. 12/14/2021. Back to Basics Tutorials.
    1. 12/14: Noridian will offer a tutorial series for new provider staff members to gain exposure and learn more about the basics of Medicare.
    2. 03/08: Tutorial sessions are in development and will be available by early summer.
    3. 06/14: We are still on track with the goal of to begin publishing the basic tutorial series and will provide an additional update on our progress in September.
    4. 09/13: Due to an unexpected leave of absence, this program will be a top priority and expected to be coming out soon. Exciting News! The Medicare basics will be developed into a 2-day Symposium being planned for March 8 and 9 - March into Medicare.
    5. 12/13: We are excited to offer our March symposium. It is our plan to have the "Save the Date" announcements published soon. We are finalizing the session topics to prepare for a successful event. The original idea stemmed from POEAG, and we are proud to be able to meet your recommendations.
    6. 03/14: The two-day event was held March 8-9, 2023. The topics presented included enrollment, touring the CMS and Noridian websites, reviewing beneficiary notices for Part A, MSP, Part A bad debt, using the Noridian Portal, claims submission and reading the remittance advice, fee schedule indicators, appeals, preventive services, and review processes. Feedback received was very positive.
    7. 06/13: Email sent to POEAG members on June 9 included links to the recordings for each of the March Into Medicare, Back to Basics webinar recordings. These will be available to view until the beginning of September. POEAG members requested copies of the presentations, and these were provided after today’s meeting.

      Noridian has been developing the Basic Medicare series tutorials that will be available on our website under the Education tab. The first one is the "History of Medicare". Additional tutorials will include MAC jurisdictions, participating vs non-participating providers, ABN and beneficiary forms. POEAG members may submit additional ideas for tutorials through the POEAG email. The plan is to publish 2-3 basic tutorials per month until the series is completed.
  2. 9/13/2022. Skilled Nursing Facility (SNF) Demand Bill Education.
    1. Topic was not conducted in previous SNF Noridian education and outreach. Noridian will work to educate on the regulatory privileges for all Medicare beneficiaries, include the right to demand a bill to be sent to Medicare.
    2. 03/14: Noridian is producing an Education-on-Demand Tutorial. The tutorial was expected by the end of 2022 and has been moved to the end of March 2023.
    3. 06/13: Noridian continues to work on this education and is confirming information included in the CMS manual. A POEAG member offered to help with this education.
  3. 9/13/2022. Evaluation and Management (E/M) translation of ‘prescription drug management’ meaning for the 2023 guidelines.
    1. People are getting hung up is on the translation of ‘management’ and that the MDM column 3 is now ‘risk of test or treatment to the patient management’. There is a mindset that because it says prescription (RX) management, if a provider prescribes, then they get credit for this area.
    2. Noridian’s Response: One drug is not the same as the next. Prescription drug management documentation would need to show the work and/or risk involved by the billing provider when managing a prescription. Is the prescription something that could be harmful to the patient’s health? Will it interact with other drugs the patient is taking? Is the prescription a non-complex drug for a patient with no allergies or complications? Example - a patient taking anticoagulants. Did the patient have a stroke? Is there a risk they may bleed out?
    3. POEAG recommended this would be one of the best topics for planning upcoming webinars. POE will take this to the Medical Directors to pursue with CMS or publish specific by Noridian. The member stated there should be more structure with managing these services.
    4. 12/13: POE is working with Medical Directors for educational opportunities.
    5. 03/14: POE is working with our Medical Directors to see how we can put together this educational opportunity. It may be an opportunity to put together another webinar or an article and include the Prescription Drug Management.
    6. 06/13: Review draft article included with agenda. POEAG members provided feedback during the meeting. Based on the feedback, we will continue to work with the Medical Directors.
      1. Providers are looking for specific documentation requirements. Compliance staff find a challenge educating clinical staff without specific documentation guidance. Other MACs have posted specific documentation requirements.
      2. Internally, staff is looking for the condition requiring medication management.
      3. Members requested including scenarios that would not support medication management. Example: provider refilling medication that is more preventive and the provider is not managing a condition. Medicare is based on lab results.
      4. In the spirit of burden reduction and documenting less, providing documentation guidance for prescription management would benefit providers.
  4. 03/14: Request training sessions for End Stage Renal Disease (ESRD) Billing to include the use of modifiers.
    1. Modifiers AY, JW, and JZ were mentioned
    2. Noridian has tentatively planned an ESRD webinar in August
    3. 06/13: A member requested the education includes the purpose of the modifiers and how to use the modifier if the patient is receiving ESRD services. Also, include how to find if the patient is under ESRD treatment, possibly under eligibility.

New Agenda Items

Prior to the meeting, Noridian solicited agenda topics from members and evaluated significant program changes to discuss.

  1. Critical Care Time - CMS Internet Only Manual (IOM) publication 100-04, Chapter 12, Section 30.6 is inconsistent with critical care time increment of 104 minutes as a threshold when billing one and a half hours of critical care time. Should providers follow time indicated in the CPT tables or the Noridian article?
    • CMS requires the maximum time for 99291 and a full 30 minutes for 99292 before billing both codes for critical care time. CMS issued Change Request (CR) 12982 that addresses the Critical Care time as a whole. The CR clarifies the reporting threshold time for the add-on code for critical care services is the same for split (or shared) critical care as for critical care that isn’t split (or shared). Use CPT Code 99292 to report additional, complete 30-minute time increments provided to the same patient, therefore it isn’t reported until at least 104 minutes are spent (74 + 30 = 104 minutes).
  2. Skilled Nursing Facility (SNF) Five Claim Targeted Probe and Educate (TPE)
    • CMS Change Request (CR) 13164 provides guidance on the strategy to reduce improper payments for SNF claims and educate providers on correct billing.
    • Medicare Administrative Contractors (MACs) will sample five claims from each SNF under all jurisdictions. Noridian will start sending letters out in June. This is a multi-year project.
    • Global and one-on-one education will be available.
    • A member commented the during the public health emergency, waivers allowed SNF’s to cover beneficiaries in the facility without a three-day acute hospital stay and the extra 100 benefit days, allowing a beneficiary 200 Part A SNF days during the pandemic. CMS had initiated the Patient Driven Payment Model (PDPM) for SNFs right when the pandemic hit, and facilities were learning a brand-new payment model to submit claims. The data may be skewed and SNF providers may benefit from the TPE process.
    • Members asked which address the letters will be mailed to, and if the letters will be available in the portal. Would a follow-up call to the SNF be made if the documentation isn’t received? There is a concern the letter may not reach the correct department and these letters are time sensitive. SNFs may not be familiar the requirements to provide medical records and will need to have staff available to respond to the TPE requests.
    • Noridian’s response: The letters will be sent to the Pay to address on file. The usual ADR process will be followed which allows 45 days to respond. If requested records are not received, there will be an automatic denial. SNF facilities that have assigned themselves to receive ADR letters via the portal will be able to view the letters through the Noridian portal.
      • Claims that include a COVID diagnosis will be excluded from this review. This may not be possible to exclude if when the claim was submitted, the COVID diagnosis was omitted.
      • The effective date for this CMS directive is June 5, 2023, which will be when the project can start. This does not reflect the dates of service that may be requested for the TPE.
  3. Consolidated Billing Updates Relative to Proposed Rule Changes
    • CMS issued the July 2023 Quarterly Update in CR 13192
    • The proposed rule was published in the Federal Register on April 10, 2023. Comments were due by June 5. As a MAC, we cannot educate on proposed rules until we receive direction from CMS.
  4. CERT Reviews - Noridian CERT team member provided the CERT process
    • Error rates are released once the round closes. CERT is currently in the 2023 round. The 2022 round closed in August and included claims from 2020-2021. The improper payment error rates for 2022 are: Part A - 8.86%; Part B - 8.21%
    • Most common errors or findings
      • Part A is insufficient documentation.
        • Could be an order, signature attestation, etc. We also see some significance in incorrect coding (billed too high, should be down coded).
      • Part B is insufficient documentation, order is missing or inadequate.
    • CERT process is a post-pay audit
      • The CERT contractor (third party) reviews the medical records and may take up to 76 days. They send out requests for documentation and will determine (agree/disagree) if the claim was originally processed correctly. The MAC will adjust the claim to pay or deny based on the findings.
      • Providers may submit additional documents to CERT if they were missing information, otherwise they can appeal the claim with Noridian and overturn the decision if it is favorable. This is an administrative burden for both the provider and the MAC.
      • A member commented on unusual CERT activity regarding signed orders. CERT is denying claims for lack of a signed order and the MAC is finding favorable through an appeal. Will the MAC be dinged if the CERT error is overturned through a MAC appeal?
        • Noridian’s response: There is a direct CERT contact person to reach out to if there is a trend with an error from CERT that is consistently found favorable through the MAC appeal process. If there is a favorable appeal finding, the MAC will not have a CERT error assessed. However, if the provider simply resubmits a new claim or goes through reopening, the CERT error will remain on the MAC’s error rate. If the same information is provided to the CERT contractor and the MAC appeal, this may be something we address outside of this meeting.
  5. Targeted Probe and Educate (TPE) Reviews
    • After a TPE has completed, will providers receive a closure notification if favorable results are determined, and it is not necessary to go into round two?
    • Noridian’s response: TPE samples include a review of 20-40 claims. Once the sample has been selected and reviewed, the files will be analyzed to determine the error rate found on review. Each case file will receive a findings letter that will provide details about the review, including the error rate. The findings letter will provide further information on whether the file will be moving to a subsequent round. The findings letter is mailed to the pay-to address provided to PECOS. Any questions can be sent to the case manager identified in the initial TPE letter.
      • A member questioned the TPE reviews that appear to stay open after receiving a favorable letter. Noridian shared the TPE will remain open until the complete sample has been finalized. If a sample of 40 claims was requested and only 20 have been reviewed, the TPE will remain open until the remaining sample of 20 claims has been requested and reviewed. A closure notification letter will be sent once the TPE has completed.
  6. Skilled Nursing Facility (SNF) Public Health Emergency (PHE) Unwinding
    • End of the PHE will eliminate the waiver for the required 3-day acute hospital stay. A member asked if this changed to 7-days? Per the SNF 3-Day Rule Billing, this stayed at 3-days.
    • Telehealth for SNF physician visits ended for new patients. Attending SNF physician or the SNF physician medical director must visit their patients in person. Established patients may continue to receive telehealth visits through December 31, 2023. (Question 23 from CMS FAQ)
    • SNF Medicare Part A benefit days limited to only one hundred SNF days per benefit period. There is not an additional 100 days of SNF benefits after the PHE ends.
    • Plus, all other SNF PHE waivers and SNF PHE flexibilities ended on May 11, 2023.
    • Members asked to have clarification on PHE ending for SNF. The CMS resources are helpful however, sometimes it is difficult to determine which resource supersedes another resource.
  7. Education for end of the Public Health Emergency (PHE) - suggestion received from March 2023 POEAG.
    • Has anyone encountered a waiver or flexibility that has ended and was not able to find a resource to reference?
    • Are there any areas Noridian should be aware of that may be causing questions at your facility?
    • We want to hear about experiences from POEAG members.
  8. Education request received through surveys: Portal Education - Reviewing options for resources and education for providers to learn how to use the Noridian Medicare Portal (NMP).
    • Which options would POEAG members recommend:
      • Live - offered multiple times throughout the year
      • Recorded and available at all times - is the favorable option. This will help with staff turn over to allow continued education for new employees.
      • Other options
    • Noridian is discussing options to have a test site to show live portal usage. There has been HIPAA concerns with showing a live version of the portal.
  9. MAC Customer Experience (MCE) Satisfaction Survey Update: Surveys reflect the webinar presentation content is informative. We review the survey comments and look for opportunities to improve educational topics, webinar materials and presentation skills. Here are a few comments from recent webinars:
    • Participants continue to appreciate the knowledge they receive from our events.
    • Grateful for the time allowed to answer questions. We have made changes in the education time by utilizing rolling slides to provide reminders and spend quality education time on the content of the presentation topic.
    • Including polling questions or web site tours are always a favorite to be engaged during the webinar. Showing how to locate information on the website.
    • Opportunities continue to request participant claim examples or specific scenarios. The scenario may not include all pertinent information and the answer provided could be misconstrued for a similar, yet different, situation.

Upcoming Education and Training Events

Providers can view Ask the Contractor Teleconferences (ACTs), webinars, and related training opportunities by visiting the "Education and Outreach/ Schedule of Events" section of our website.

Webinars and Schedule of Events

2023 Ask the Contractor Meetings (ACMs)

CMS requires quarterly ACMs (formerly ACTs). Noridian offers a question-and-answer portion within each webinar to help streamline applicable topics, audience, and questions for experts.

  • March 22 (Part A), April 19 (Part B), August 30 (Part A), and October 11 (Part B) from 3-4 p.m. CT, 2-3 p.m. MT, and 1-2 p.m. PT
  • Submit questions in advance through the Pre-Question Process on our website

Please share recommendations for any timing, frequency, size, topics, and provider type(s) for the 2023 ACM schedule.

Provider Contact Center Training

CMS approves training for Customer Service Representatives (CSRs) for up to eight hours per month. The training improves consistency and accuracy, understanding of issues, and knowledge retention. POE participates in training Customer Service Representatives each month.

POEAG member recommendations for PCC training topic or related recommendations are welcome.

Electronic Mailing List (Listserv)

Noridian’s email list is routinely distributed Friday mornings with a CMS-authored MLN Connect sent out each Thursday. Noridian’s providers will benefit by seeing outreach opportunities and register as those events are available.

New POEAG Suggestions and Recommendations

During each meeting, all POEAG members are asked to provide suggestions on ways to increase education, improve training methods, CSR training topic recommendations, or elaborate on topics discussed during the meeting.

  1. Article regarding implications of copy and pasting information for history and exam components for the Evaluation and Management (E/M) service. New E/M guidelines and direction indicate to document only what is necessary.
  2. Request to provide a copy of the pre-submitted questions and corresponding answer, similar to Frequently Asked Questions (FAQ) published for Ask the Contractor Meetings (ACM).
  3. Suggestion for POE to tighten the accountability on follow-up questions promised during the webinar.

Upcoming Meetings

Meetings for 2023

We continue to meet four times per year.

When: All meeting times 2-3 p.m. CT, 1-2 p.m. MT, and 12-1 p.m. PT

  • September 12
  • December 12

Thank you for attending today’s meeting. We look forward to working with all of you again.

 

Last Updated Dec 09 , 2023