Webcast August 27, 2009

Question Number Topic Question Answer
1 Review Notification When is an entity notified that it is selected for a review? Once a payor has been selected for review, a DOH review notification letter will soon follow.
2 Claims Testing Please clarify what a "properly completed claim form in accordance with DOH directives" is. Directives were provided by DOH in letters dated May 8, 1997 and November 30, 1998. These letters can be viewed by visiting the Department of Health website.
3 Communication Protocol Does KPMG communicate with the Reviewee during the testing phase (day 75-day 115)? Does KPMG share any findings during this time? As part of the review there is constant communication with the Reviewee during the entire engagement through the use of the status tracker and scheduled status calls. A primary contact is assigned during the offsite pre-entrance conference to assist with any Reviewee questions. The period from day 75 through day 115 is reserved for testing, therefore there will be limited discussion during this time. This demonstrates the importance of communication during the first 74 days of the review. The preliminary results meeting is the formal vehicle for communication of any variances noted during the testing phase.
4 Data Please explain the procedure for instances where historical data was not archived, or was overwritten, etc. If historical source data is not available, then alternative procedures are determined based on the individual situation. If alternative procedures are used, the reviewee is not eligible for any overpayments noted. The lack of data may also result in civil penalties, which would be applied by DOH.
5 Data If pharmacy claims are paid and recorded in a separate pharmacy system, should those claims be included in the data dump provided to the Reviewer (even though they may not be subject to surcharge)? Yes, the complete universe of claims data for the period under review should be provided.
6 Data What if electronic data is not available but hard copies still exist? Does this fulfill DOH requirements? Yes, if the electronic documentation is not available a paper version of the same information would be an acceptable form of proof for a review.
7 Data How do we submit data for Pharmacy, Dental, etc that has different data structure or additional fields needed (e.g. tooth #)? Can multiple data files submitted with different layouts? Yes, multiple data files with different layouts will be accepted for review. A data dictionary for all data structures should be provided.
8 Discrete Physician Billing for Private Practicing Physicians How is discrete physician billing for private practicing physicians treated during a review? Occurrences of Discrete Physician Billing for Private Practicing Physicians require reviewees to submit sufficient support as noted during the webcast on 8/27/09. The following is the list of four types of documentation that may be accepted:
  1. A signed letter, on the provider's letterhead from the designated provider which indicates the physician group for which they discretely bill. Provider TIN must be noted on the letter and the letter should be signed by an officer of the facility.
  2. Cancelled checks addressed to the private practicing physician who is billing discretely in an Article 28 facility. Physician TIN must be noted on the cancelled check.
  3. 1099 for the private practicing physician who is billing discretely in an Article 28 facility. Physician TIN must be noted on the 1099.
  4. Properly completed provider certification form with either box 1 or box 3 properly completed. Provider TIN must be noted on the form.
9 Discrete Physician Billing for Private Practicing Physicians How can a cancelled check provide supporting documentation? What if the TIN is not on the check? A canceled check would establish the payee that received the claim payment. The TIN would be required to link the support back to applicable claim records.
10 Discrete Physician Billing for Private Practicing Physicians Many providers use Social Security numbers on their checks rather than TINS (FEINs). Are there privacy issues for putting their check with Social Security numbers as documentation? A process to tie any applicable support provided back to the data under review is necessary. The preferred method would be the use of a TIN (FEIN) due to the unique nature of this identifier.
11 General When will the HCRA website FAQ`s be updated as it was supposed to be updated as of January 1, 2009? DOH has been in the process of updating the FAQ's. This will be an ongoing process and the updates will appear on the website when completed and updates will follow when applicable.
12 General When will the Provider TINs (FEINs) be added to the DOH website? Surchargeable Provider TINs (FEINs) will not be added to the DOH website. However a listing of surchargeable TINs (FEINs) can be found on the Pool Administrator Web site at http://www.hcrapools.org where it has been posted since July of 2008. A username and password is required for access to this Web site.
13 Medicare Medicare participants become eligible on the 1st day of the month that they turn 65, so if someone is 10 days shy of their 65th birthday and see a doctor on the 3rd of the month, that shouldn't be taxable. Questions in regard to Medicare eligibility please refer to the Medicare website.
14 Medicare Please provide Dx codes that are allowable for ESRD. Please provide acceptable examples of "proof that the member met certain requirements of Social Security". What is proof of eligibility here? Also, the HCRA language relates to "eligibility" and not "having Medicare". To be Medicare eligible for End Stage Renal Disease (ESRD), multiple criteria must be met. Once Medicare eligible there must be Medicare coverage for the claim to be excluded from the surcharge. If you have any questions in regard to Medicare eligibility please refer to the Medicare website.
15 Onsite Conference Does KPMG typically provide reviewees a background of what topics are covered in an interview? The areas of discussion noted in the Review Notification Package are the basis for the initial interviews that are scheduled. Interviews typically consist of a walkthrough of the HCRA areas the specific personnel are involved in. The walkthrough serves as a starting point for discussion, which then leads to follow up questions.
16 Preliminary Results Can KPMG send back the results in the same form as the submitted data with the few additional fields that they've provided? The results for both claims and CLA testing are sent back to the reviewee in the form received, with additional fields added to note the result determinations.
17 Preliminary Results Is the reviewee responsible to reconcile the results from the CD to the preliminary results report? Can KPMG provide such a reconciliation? Preliminary results and corresponding data will be provided to the reviewee, and will include a walkthrough to explain the reconciliation of the data to the preliminary results.
18 RSA/Capitation How does the HCRA surcharge apply to capitation arrangements, when it is based on per member, per month? A surcharge must be remitted for all surchargeable services provided. For per member per month payments the reviewee should establish a methodology to calculate the percentage of services provided which are surchargeable. This methodology must be approved by DOH.
19 RSA/Capitation Please provide an example of a situation where the surchargeable amount would be less than 100% of the capitation payment to an Article 28 provider as it relates to DOH's approval of capitation agreements. DOH's approval as it relates to capitation agreements, is only required when the capitation arrangement results in less than 100% payment. Since capitation agreements can cover a wide range of services, there may be instances when both surchargeable and nonsurchargeable services are included. For example, if a capitation agreement covers visits to a private practicing physician's(PPP) office, as well as inpatient surgical procedures, it may be necessary for the reviewee to develop a methodology to distinguish between the two. The PPP office visits would not be surchargeable, while the inpatient surgical procedures would be. All methodologies should be discussed with DOH to obtain approval.
20 RSA/Capitation How does the surcharge apply to dental capitation paid under a stand alone dental plan where there is no inpatient hospital benefits under the dental plan? Dental services provided at an Article 28 facility are surchargeable. However, dental services provided at a non-Article 28 facility are not surchargeable.
21 Settlements Should all settlement records be provided during the review period? Would a sample be acceptable if pulling a full population of these records would be an unreasonable amount of work for an review? A sample of these records is not acceptable. All settlement or bulk payments paid outside of the claims processing system for the periods under review should be provided.
22 Surcharge Exclusions Why won't KPMG/DOH provide, at a minimum industry standard definitions? Mostly UB "Type of Bill" fields and HCFA "POS" fields? DOH's Home Health/Hospice/SNF "Acceptable Responses" completely ignore the use of the UB "Type of Bill" field which is important because facilities bill for these services, and they don't use POS codes. Providers often get POS codes wrong. Will you accept Home Health / Hospice / SNF CPT-4 codes that would be billed by a provider? Accuracy of these fields would be better than POS. Payors and providers have many different types of systems and their identifiers are not uniform throughout the health care industry. Payors and providers need to make the reviewers aware of any unique coding that they use to identify whether or not a claim is surchargeable for any service and also be able to provide the source documentation to back up that determination. These codes will then be tested as part of the review and the results presented to DOH for approval.
23 Surcharge Exclusions Are Psychological and Substance Abuse facilities surchargeable? What if the services are provided at Acute care hospitals? Psychological and substance abuse services provided at an Article 28 facility are surchargeable. However, psychological and substance abuse services provided at a non-Article 28 facility are not surchargeable.
24 Testing Methodology Is the decision tree that KPMG mentioned that is included with the testing results also included when the testing methodology is sent to the reviewee for approval? No, but it will be going forward.
25 Third Party Administrator Would the HCRA surcharge affect us if we are a TPA based outside of New York State? Our client groups are elected into the Pool and we pay surcharges for patient services and covered lives as required. Do these types of reviews apply to us? Yes, electing third party administrators (TPA's), whether domiciled in New York State or not, are subject to review.
26 Timeline Does the timeline described in your slide deck apply for companies with multiple claims systems? Yes, the timeline provided was developed with the consideration of multiple systems for both claims and membership.
27 Timeline Is the timeline based on business days or calendar days? The timeline is based on business days.