Texas Department of Insurancewww.tdi.state.tx.us - Consumer Helpline 1-800-252-3439
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Texas Department of Insurance AGENDAJanuary 11, 2006
Meeting NotesJanuary 11, 2006 Audrey Selden welcomed the group and reviewed the antitrust statement and ground rules. She noted that TDI has a new Associate Commissioner for Life, Health & Licensing, Jennifer Ahrens, who co-chairs the TACCP. Updates Thank you to Teresa Devine and the Texas Medical Association for providing information to update the TACCP on these topics: - AMA report on national bundling standard: Because the AMA was conducting a major feasibility study on standards for bundling and coding, the TACCP decided to wait until the study was completed before advising the Commissioner on standard coding and bundling logic. The study has been presented to the AMA House of Delegates and the recommendations were not adopted. See attached letter from AMA explaining that it has determined not to undertake this effort because many stakeholders are involved over which AMA has no authority. Audrey noted that such an effort may be more appropriately led by the federal government. TDI will contact CMS, other states, vendors, and experts, for latest information on this topic. At the next meeting, TDI will invite representatives from these groups for a panel discussion regarding a standard for coding and bundling. - National Provider Identifier (NPI) and revised CMS 1500 form: Providers have begun applying for their NPIs. Guidelines for how large group practices can apply in a "mass application" are still being developed by CMS. Payers should be working on crosswalks between their current IDs and the new ones. Implementation of the NPI will require modifications to the health claim form and the Texas clean claim elements. For more information about the NPI, please go to http://www.cms.hhs.gov/apps/npi/01_overview.asp. For more information about proposed changes to the health claim form, please see the National Uniform Claim Committee (NUCC) web page at http://www.nucc.org/. Scroll down to the section titled "The NUCC Approves a Revised 1500 Health Insurance Claim Form" to view the form in various formats. For the reference manual, click on http://www.nucc.org/images/stories/PDF/instruction_manual.pdf. Please send suggestions, comments, or concerns regarding changes to the Texas clean claim elements to the group mailbox taccp@tdi.state.tx.us by January 27. In the Subject line of your e-mail, please type "Clean claim rule suggestions." TACCP input will assist TDI staff in drafting a rule regarding changes to the Texas clean claim elements for consideration at the group's next TACCP meeting. Patricia Kolodzey will research implementation of the NPI for the UB-92 claim form and report at the next meeting. Any "covered entity" or anyone who provides medical care may apply for a NPI. Please see the CMS NPI web resource page at the link above for guidance. - Proposed electronic claim attachments: CMS is asking payers, physicians, and providers to complete a short survey in order to gather more information. Please complete the survey on the NUCC web page at this link http://www.nucc.org/. Standards for electronic claim attachments will be adopted by the end of the year and the proposed CMS rules are very technical. A copy of the American Hospital Association's comments are attached. - Issue with electronic claims processing and clearinghouses: TDI recently received some complaints from providers regarding clearinghouses that were dropping electronic claims to paper then mailing the claims to payers. If a payer changes its designated claims payment address, then the payer must notice providers 60 days in advance of making the change. If an electronic claim is submitted by a provider and received at the payer's designated claim address in electronic format, then the claim is subject to the 30-day prompt pay timeframe for electronic claims. Cheri Parten from Aetna added that this happened with two clearinghouses and some Aetna claims. Aetna and the two clearinghouses have reached an agreement and the two clearinghouses have stopped this practice. TDI will add an FAQ on this topic to the provider web page. Audrey reminded providers that if providers determine that their claims have gotten "lost" or were not timely received by the payer due to any issue with a clearinghouse, they should file a complaint with TDI. TDI will add an FAQ on this topic to the provider web page. In addition, an agenda item for the next TACCP meeting will be an update regarding this issue. Prompt pay and other recent rules Members received copies of five rules adopted by TDI regarding prompt pay and recent legislative changes are on TDI's website at the links below. Ryan Tredway explained that TDI has received a letter with a chart (attached) from attorney Elizabeth Rogers regarding language in some providers' contract that could be misleading as to prompt pay. Ryan asked the TACCP to review the information and comment on what action TDI should take in an e-mail to the TACCP e-mail address taccp@tdi.state.tx.us.- SB 50 rules (contract requirements and batch rejections):
- SB 51 rule (single service dental and vision HMOs) - Clarifications re: batch rejections, patient responsibility, underpayment penalty calculation, reporting date clarification, other - SB 1149 (eligibility statements) Pati McCandless provided a handout regarding the underpayment penalty calculation (see copy attached to these notes) to illustrate that in some instances, an underpayment penalty could exceed a late payment penalty. She asked the members to consider the public policy implications. Underpayment penalty calculations will be added to the agenda for discussion at the next meeting. Excel Chart (.xls) | Word Document (.rtf) TDI has posted an informal draft rule to implement additional SB 51 provisions relating to the obligation to continue premium payment and coverage after notice that an individual has lost group eligibility. To review the informal draft rule, please click on http://www.tdi.state.tx.us/rules/life/lhsb51ruleid.html. New Issues Margaret Lazaretti gave an overview of how TDI assesses "network adequacy" for HMOs regarding hospital based physicians. TDI reviews provider listings, and for each hospital, identifies which providers are contracted or non-contracted. If a hospital relies on non-contracted providers, TDI requests an access plan. TDI also looks at how the HMO informs enrollees that they will have a higher out-of-pocket cost if providers are not contracted. If a plan had no contracted providers at a hospital, then TDI would look closely at this situation. If members have concerns regarding network adequacy, please let TDI know. Audrey summarized the prompt pay provisions regarding underpayments. Providers who notify a carrier of an underpayment within 180 days are entitled to the contracted rate and a penalty payment. In a different scenario, if a provider notifies a payer of an underpayment after 180 days and within the appeal deadlines of the contract, then the provider is owed the balance of the provider's contracted rate. In this scenario, the provider is not entitled to the penalty payment. Also in this scenario, if the carrier does not pay the amount owed within 45 days of the notification from the provider, then the carrier owes the underpaid amount plus penalty. TDI will check to make sure this is outlined in the FAQs. TMA shared a recent AMA article on silent PPOs. TACCP members are asked to review the article and send comments about how TDI can address this issue to the taccp@tdi.state.tx.us mailbox. Silent and rental PPOs will be an agenda topic at the next meeting. Education TDI is going to update the Physician/Provider web resource page. In particular, TDI would like suggestions for how to make it more user-friendly. Please send suggestions to taccp@tdi.state.tx.us. TDI would like to partner with carrier, physician, and provider groups on prompt pay education so please let TDI know of upcoming workshops, meetings, or other opportunities. TDI is considering dates for a compliance workshop for the industry and will consider one for providers as well. At the next meeting, TDI will present a draft outline of the TACCP report for members' review. All suggestions welcome, please send to the taccp@tdi.state.tx.us mailbox. The report will be an agenda item for the March meeting. TDI has received some complaints where a pharmacy is insisting that the doctor provide a DEA number for a non-controlled substance because the carrier requires the DEA number in order to pay the claim. Audrey reminded the carriers that TDI has issued two bulletins stating carriers should not request DEA numbers on all prescriptions. To view the bulletins, click on http://www.tdi.state.tx.us/bulletins/b-0040-6.html (1996 and 1992 bulletins shown on same page). TDI is considering another bulletin on this matter. In December 2005, United Healthcare was fined $4,000,000 for violating Texas prompt pay statutes, failure to file complete and accurate provider claim data reports, and failure to maintain adequate complaint logs and complaint records. UHIC agreed to pay restitution for failure to properly pay statutory penalties on late clean claim payments, and additional contingent penalties for future similar violations. TDI continues to monitor carriers compliance with prompt pay through complaints, quarterly data reports, and other means. Aggregated data about timeliness of claims payment and complaints will be included in the TACCP report that is due before 9/1/06. A summary to date will be provided to the members at the next meeting. Provider members with concerns about how particular claims were handled should file a complaint with TDI. Open discussion Pat Harris reported that some doctors have complained that carriers' customer service staff cannot provide written confirmation documenting the substance of customer service communications with the provider because of an internal policy. Nathalie Woolfrey explained that typically customer service representatives do not have the ability to provide written confirmation because they don't have access to word processing software, e-mail, and fax to make a screen print and e-mail or fax it. However, provider relations staff do have this capability and they can access the same screens the customer service representatives use. So an alternative is for a doctor's staff member to ask the provider relations representative to provide written confirmation. Or providers can do a screen print from a web portal. Virgil Dice suggested the physician may wish to send a "negative confirmation" to the payer's fax number. Regarding overpayments from payers, several providers reported that they have repeatedly tried to return overpayments to payers that then do not take corrective action to fix the system error that is causing the problem so overpayments continue. Cathy Andrews wondered if providers could simply stop sending overpayments back if they have notified the payer and the problem persists. The group is asked to clarify what remedy they are seeking from TDI. Mike Pollard reported that coordination of benefits on Medicare claims, where providers are receiving multiple payments by both the primary and secondary payers, is a problem. TACCP members agreed to provide examples. The next meeting will be on March 8 at 10 a.m. in room 102. Agenda topics will include: National bundling standard, the NPI and clean claim elements, clearinghouses, underpayment penalty calculations, clearinghouses, silent PPOs, and the TACCP report outline. For more information contact: ConsumerProtection@tdi.state.tx.us Last updated: 07/09/2007 |
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