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Claims Processing - January 30, 2008

Agenda - January 30, 2008

  • Antitrust Statement, Review of Ground Rules by Jennifer Ahrens, Associate Commissioner, Life, Health & Licensing.
  • DWC - Clean Claim Companion Guide by Allen McDonald, Director, Information Management Services, Division of Worker's Compensation.
  • DWC - Find a Doctor Brochure by Allen McDonald.
  • Medicare Advantage Marketing by Jack Evins, Director, Advertising Unit, Consumer Protection.
  • Chiropractic Mini Conference and Resources by Valerie Brown, Director, Complaints Resolution, Consumer Protection.
  • Legislative Updates: HB 472, HB 522, HB 1594, SB 1884, SB 1731 by Jennifer Ahrens, Doug Danzeiser, Deputy Commissioner, Regulatory Matters, and Katrina Daniel, Special Advisor for Policy Development, Life, Health & Licensing, and Dianne Longley, Special Projects Director, Data Collection.
  • Lunch.
  • ICD-10 Codes by Teresa Devine, Director, Payment Advocacy, Texas Medical Association.
  • Prompt Pay Compliance Data Calls by Katrina Daniel.
  • Present on Admission by Katrina Daniel.
  • Prompt Payment Penalty Settlements by Katrina Daniel and Doug Danzeiser.
  • Recovery of Overpayments and Auditing Claims by Katrina Daniel and Doug Danzeiser.
  • Discuss Dates for Next Meeting by Group.

Proposed TACCP Calendar of Events

  • Date: January 30, 2008, Event: TACCP Meeting Room 102, Select Topics and ask for volunteers to participate in the writing of the report of activities.
  • Date: April 21, 2008, Event: Deadline to submit text for the first draft of the report.
  • Date: April 30, 2008, Event: Proposed TACCP Meeting Room 102 - Distribute the first draft of the report.
  • Date: July 30, 2008, Event: Proposed TACCP Meeting Room 102 - Review final draft of report.
  • Date: August 6, 2008, Event: Comments/Edits due on final draft of report.
  • Date: August 13, 2008, Event: Revisions completed/send to the Commissioner.
  • Date: August 20, 2008, Event: To the printer.
  • Date: September 1, 2008, Event: TACCP report due to Legislature.

Meeting Notes


Jennifer Ahrens welcomed the TACCP members and observers and read the antitrust statement and meeting ground rules.

Division of Workers' Compensation (DWC) - Clean Claim Companion Guide:
Allen McDonald from DWC's Information Management Services provided highlights of the changes implemented by DWC. A new version of the Texas Clean Claim and Electronic Medical Billing and Payment Workers' Compensation Companion Guides were released on January 9, 2008. The guides align the workers' compensation (WC) e-Bill transaction standards to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), which will allow health plans to use the same system on WC claims. At the national level, WC codes were approved to be added to the HIPAA implementation guides. The requirements provide that health care providers be able to process electronic claims; however, if they are not able to process them electronically, then paper claims may be submitted.

DWC - Find a Doctor Brochure:
Because approved doctors' list has been abolished, DWC has developed a "Find a Doctor" brochure aimed at educating injured workers who are not part of a network on how to find a doctor who accepts WC claims. TACCP members may monitor the Department website for the posting of this brochure.

Medicare Advantage Marketing:
Jack Evins reported that TDI participated in monthly conference calls with the Centers for Medicare and Medicaid Services (CMS) and signed a memorandum of understanding to facilitate information sharing. The Department issued a Commissioner's Bulletin Number B-0044-07 on November 1, 2007, to remind all regulated entities of their responsibility to comply with both federal and state law regarding Medicare Advantage plan marketing. The Department adopted emergency rules on November 9, 2007on Medicare Advantage Plans, Medicare Advantage Prescription Drug Plans, and Medicare Part D Plans. TDI is working to resolve numerous complaints and conducting outreach to seniors and organizations.

One member expressed concern that the networks were not adequate to meet the patients' needs, often resulting in a request for disenrollment. Mr. Evins confirmed that the Consumer Protection Program is aware of the concern.

Another TACCP member asked if the Department website has information on complaints filed against plans. Mr. Evins responded that although the information is not on the website at this time, he would follow-up on implementation options.

Chiropractic Mini Conference and Resources:
Valerie Brown gave a brief overview of Department outreach steps, including holding a mini conference last fall to inform chiropractors of TDI resources available to them, the process for filing formal complaints, and prompt pay laws. The Department will put a link on TDI's provider resource page for chiropractors.

Legislative Updates:

House Bill 472:
Ms. Ahrens stated that informal draft rules for HB 472 were issued and the Department received comments. Proposed rules will issued by the end of February 2008. Members were directed to send any questions to Ms. Ahrens or Matt Ray. Since the last TACCP meeting, the lead program on these rules has changed to the Financial Program. Please direct any questions regarding these rules to Kevin Brady.

House Bill 522:
Doug Danzeiser informed the committee that HB 522 requires the Department to develop a pilot program to create electronic identification cards that contain health insurance eligibility information. The pilot will be limited to one county, which is currently anticipated to be Travis County. TACCP members were informed of the upcoming Technical Advisory Committee on Electronic Data Exchange (CEDE) meetings held the third Wednesday of each month. Members may send their ideas to Mr. Danzeiser.

One TACCP member expressed concern that providers would end up with multiple card readers for different carriers. Mr. Danzeiser responded that the Workgroup for Electronic Data Interchange (WEDI) issued guidelines for the magnetic strip, which should eliminate the need for multiple readers.

House Bill 1594:
Mr. Danzeiser stated that HB 1594 requires expedited credentialing for new providers in medical groups. However, as worded, the definition of medical group is limited to very few medical groups. The bill's author has clarified his intent, and the Texas Association of Health Plans (TAHP) issued a letter stating that it would work with its members to comply with the author's intent. At this time, the Department doesn't anticipate adopting rules, but will monitor complaints and amend rules at a later date, if needed.

Senate Bill 1884:
Katrina Daniel informed the committee that SB 1884 adjusts the calculation for underpayment penalties under the prompt pay statutes. The Department is currently updating this information on its website. The adoption order for the rules was signed on January 18, 2008, and is scheduled to be published in the Texas Register on February 1, 2008.

Senate Bill 1731:
Dianne Longley informed the committee that SB 1731 requires providers to provide patients with notice of billing practices. In addition, the bill requires the Department to collect information about health care pricing practices. Ms. Longley stated that the Department will collect data on several hundred services. Informal draft rules will be issued in the next few weeks, with the target date for the first data submission as September 1, 2008. Information will be on the website by early November, 2008.

Report card information will have staggered implementation, and the Department will issue draft rules this summer.

The Network Adequacy Advisory Committee (NAAC) met last week on the network adequacy study. The hospital association will work with the Department to collect information The NAAC will meet monthly, with the next two meetings scheduled for February 26 and March 26 at 1:00 p.m. The Department will offer teleconferencing.

One TACCP member expressed concerns that consumers don't know to ask hospitals and health plans for estimated costs, then they are balance billed from the non-participating providers. There is a need to ensure that the customer service representatives know how to direct calls to get the consumer to the right source for information.

ICD-10 Codes:
Ms. Daniel introduced Teresa Devine with the Texas Medical Association for the presentation on the ICD-10 Codes.

Teresa Devine said that it is generally understood that ICD-9 Codes no longer serve the needs of the health care community. The rest of the world now uses the ICD-10 Codes, with the United States lagging behind. Concerns resolve around electronic transmission, difficulty reporting, the need for form updates and possible legislative action. ICD-10 Codes are planned for implementation in 2012.

Prompt Pay Compliance Data Calls:
Ms. Daniel informed the TACCP members that the prompt pay database is being updated and that the goal is to have the new system up for the next quarter.

Present on Admission:
Ms. Daniel said that concerns were expressed that some claim forms include present on admission indicators and may be rejected by carriers when the field is completed. Medicare is still rejecting claims with that field filled. One TACCP member stated that some claims are rejected when level 2 CPT codes, which are required for Medicare, are not used. The entire claim can be rejected if the processor doesn't recognize it as a valid code. Ms. Daniel asked the TACCP members if there were other extra items on the claim forms that cause them to be rejected. The committee responded that the present on admission indicators and the level 2 CPT codes are the two main ones.

Prompt Pay Penalty Settlements:
Ms. Daniel asked the committee if this was an issue that needed to be included in the report to the Legislature. The statute says that you can't waive the penalty. The committee responded that the settlements are mutually beneficial, so the Department will not receive complaints. Settlements usually address the dispute, and the committee recommended that this issue not be included in the report.

Recovery of Overpayments and Auditing Claims:
Ms. Daniel asked the committee if the recovery of overpayments and the auditing of claims was an issue that needed to be included in the report to the Legislature. Payers have 180 days to recover overpayments, unless there is fraud or material misrepresentation. A concern expressed by a TACCP member is that if a provider is being audited for fraud, then the provider should be told up front. If the provider is not being audited for fraud, then the payers need to adhere to SB 418.

Another concern expressed was at what point does the physician get notified that they are being audited for fraud? When physicians are cleared, they receive a settlement. However, the commenter continued, the physicians are not told what is happening and are abruptly cut off from all communications and all payments stop.

One member expressed that when pharmacists challenge an audit, they are told that it is for fraud, and sometimes get notices beyond the 180-day period. Carriers responded that research is done by a special investigation unit, and no one outside that unit has information. Fraudulent performer cannot be told they are being investigated for fraud or they will not release the information needed to complete the investigation.

Fraud in pharmacy can be a result of fraud in medicine and may not be directed toward the pharmacist or pharmacy benefit manager (PBM). It may be a result of a provider fraudulently issuing prescription.

Prompt pay laws do not address when an audit can be done, only when a recoupment can be made.

TACCP Report to the Legislature:
Ms. Daniel asked the TACCP members to discuss issues to include in the report to the Legislature.

One committee member suggested that the report follow a format used in the prior reports where a topic is included with paragraphs presenting differing points of view.

Silent and rental PPOs continue to be an issue and should be included in the TACCP report.

A member suggested that one section of the report address ongoing issues for topics from previous reports that need to be brought forward, such as the coding and bundling issue.

Committee members will be contacted to draft certain portions of the report. The first draft needs to be sent to TDI by April 21.

WEDI Conference:
In closing, Katrina informed the committee members of an upcoming WEDI audiocast regarding the National Provider Identifier (NPI) Implementation.

For more information, contact:

Last updated: 9/28/2015