October 8, 2004

Summary: TAA/TMHP/HHSC Ambulance Meeting October 6, 2004

MINUTES
October 6, 2004
10:00-12:30

Introductions – Julie Griffin and Ron Gernsbacher

The Texas Ambulance Association (TAA) requested a face-to-face meeting with Texas Medicaid & Healthcare Partnership (TMHP) and the Health and Human Services Commission (HHSC) to discuss global issues ambulance providers have with claims processing since the transition from the former claims administrator to TMHP. This meeting was held at the HHSC Braker Center on October 6, 2004, in the Lone Star Conference Room, Austin, TX.

Purpose of the Meeting –Kari Dingman

HHSC stated that the most appropriate outcome of this  meeting is to ensure claims are paid appropriately and timely; therefore, plan of action will follow payment issues, interactive research, and creation of an ambulance workgroup.

The following topics were discussed.

Provider Relations

Lack of knowledge of TMHP telephone representatives. TMHP has taken measures within the last three to four months to educate the Call Center staff. TMHP consolidated their Call Centers and located staff only in Austin, TX. Originally, all Call Center staff were “generalists” and answered questions of all provider types. Call center staff are now divided according to specific provider types and are considered specialists. GRASP, a new software application, has been installed to monitor what is being said during phone calls so that training efforts can be tailored and improved.

One provider stated that she avoids calling the Call Center because of its general incompetence. She feels much more comfortable calling a specific subject matter expert who has demonstrated knowledge about ambulance claims processing with her ambulance questions.

TMHP Action Item. Call Center staff are to be trained in ambulance claims processing by the resident subject matter expert by Friday, October 15, 2004.

Inadequate review and research of telephone representatives. Another TAA member does not use the Call Center because the representatives provide inaccurate information that is in direct contradiction of the provider manual. The provider further questioned whether the representatives had access to the provider manual. According to this provider, his staff is educating Call Center staff about what information is in the manual.

In addition to this frustration, providers cannot get beyond customer service representatives if they have additional, higher-level issues or concerns. On at least one occasion, a customer service representative told a provider that they would “get in trouble” if they did not handle the call themselves.

Providers are confused as to which specific customer service representative to contact regarding ambulance claims processing. When providers do finally contact someone at TMHP about these ambulance claims processing issues, providers are often given different responses to the same questions.
 
Providers further expressed concern about the stability of the Call Center workforce. TMHP concedes that turnover is high.

TMHP Action Item. – HHSC directed TMHP to create a feedback loop from providers to TMHP management for this kind of issues. Maryann Wallace at TMHP was designated as the contact for providers if they had concerns with the Contact Center.


Claims Processing

Inappropriate denial of claims using denial code 795. TMHP assures providers that the problem of denying claims with code 795 was corrected in the TMHP system in June 2004.  The problem related to a code-mapping issue.

Providers stated that inappropriate denials were still occurring. Copies of  these  denials were submitted to TMHP for review. TMHP reiterated that the problem was corrected June 24, 2004, but that providers had claims pending for up to 11-12 weeks.

Providers were concerned about the age of claims. One provider asked that TMHP explain how claims are being aged. TMHP provided an explanation of the process.

Providers contended that the only claims that seemed to be paid were Medicare crossover claims for emergency transportation (ET modifier) and repetitive patients with prior authorization.

A representative from East Texas Medical Center (ETMC) requested that their claims be paid by October 31, 2004. He received no affirmative responses to this or any assurances from anyone that this would occur.  HHSC has had subsequent conversations with ETMC related to their issue.

Representative Norma Chavez inquired as to whether or not TMHP was subject to contract performance requirements. HHSC assured Representative Chavez that TMHP was currently engaged in a corrective action plan specific to the backlog inventory of claims adjustments.

An ambulance provider stated that few electronic claims were being paid. When claims are submitted electronically, they are auto-denied for various reasons: 1) no documentation accompanies the submissions (Run reports and ER records); and 2) comments provided in the appropriate field are automatically erased if the field contains any special characters (e.g., : ? &). TMHP explained that this is a system problem that is HIPAA-related and one they had just discovered. In the mean time, providers were instructed not to use any special characters in future claim submissions.
ETMC stated that other payors do not have an issue with this particular field or with paying providers using special characters.

Life Ambulance questioned the possibility of eliminating the ambulance run report with each claim. This issue was deferred for consideration by the ambulance workgroup that is to be created to review ambulance policies and procedures (see action item below).
 
HHSC Action Item: HHSC will create an ambulance workgroup to address specific issues (e.g., eliminating the ambulance run report). The workgroup will review ambulance rules, policies, and procedures for accuracy and appropriateness. HHSC policy analysts, TMHP customer service representatives and claims processors, and TAA representative will participate on the ambulance workgroup.

HHSC Action Item: HHSC will contact the subject matter expert about HIPAA requirements relating to electronic claims processing. HHSC also will inform participants of this resolution during week of October 11, 2004.

HHSC Action Item: HHSC will follow up with TAA about TMHP resolutions regarding the problem with the delimiters in the comments field. TMHP implemented a manual workaround on October 11, 2004. The permanent solution is scheduled for completion by November 19, 2004.

TMHP Action Item: By October 15, 2004, TMHP will give TAA the research conducted on claims to find out how they will be adjudicated to prevent future denials and suspends. TMHP has developed a solution for paper claims that deny because of blank or invalid diagnoses (when diagnosis field is not required). This solution will be implemented by November 19, 2004.

TMHP Action Item: TMHP will review problematic claims submitted by Life Ambulance within the next two months. 

TMHP Action Item: Banner message to providers about the systems issue concerning special characters.


Administrative Appeals

TAA requested that filing deadlines be extended due to the appeal backlog. The number of claims not processed by TMHP is extensive (providers have seen an increase in pending claims). Providers are considering lobbying for a bill to be introduced in the Texas Legislature about specific time frame requirements for claims payments. HHSC assured providers that the appeal backlog will not result in providers missing filing deadlines. TMHP requested that providers send them examples of appeal claims that were denied because of missing the filing deadline.


Discussions

Emergency Diagnosis. One provider requested that HHSC publish or give providers emergency diagnoses that are payable for emergency transports by Medicaid. HHSC does not support publishing emergency diagnoses. The Medicaid program supports ambulance providers coding their claims according to the services provided during the transport.


Timeline and workplan for resolution of issues.

TMHP Action Item: By the first week of December, all currently pending claims should be processed. (But will they be paid?  Not necessarily.)  There will be instances in which the claim may be denied for appropriate reasons.

TMHP Action Item: By Friday October 15, 2004, TMHP will communicate with Life Ambulance about outstanding claims.

HHSC Action Item: HHSC will schedule monthly meetings until issues are resolved. Either November 22 or 23, 2004, will be the next meeting date. The next meeting will require more time and will be divided into two parts: quick wins/short term solutions and long term solutions. The focus of the workgroup will be centered around understanding and resolving issues.

HHSC Action Item: Set up first workgroup meeting

Outstanding issue to be resolved: Why aren’t ambulance providers paid as immediately as hospitals and doctors?  Why are their claims regularly denied (on the basis of medical necessity), but doctors’ claims are not?  HHSC will add this issue to the agenda for the next meeting.