Officials and representatives attending the meeting included:

• Charles Friedrich - Chicago Regional Office of HCFA 
• Steven Fradin - Chicago Regional Office of HCFA 
• Colleen Carpenter - Atlanta Regional Office of HCFA
• David Werfel - American Ambulance Association's Medicare consultant
• Michael McCarron - AdminaStar-Federal, Inc. 
• Christine Beard - AdminaStar-Federal, Inc. 
• David Elliott - AdminaStar-Federal, Inc. 
• Mike Swift - Kentucky Ambulance Providers Association 
• Jerry Key - Indiana Ambulance Association 
• Shelley Henderson - Indiana Ambulance Association 
• Gary Miller - Indiana Ambulance Association
• Tonya Chang - Lt. Governor's office 
• Kentucky Lt. Governor Steven Henry, MD.

The following summary of the meeting was prepared by David Werfel.

ISSUES DISCUSSED:

AMBULANCE CLAIMS PROCESSORS: AdminaStar now has a specialized unit for processing ambulance claims.

CURRENT CLAIMS: According to AdminaStar, Kentucky has 3,069 claims pending with approximately 18% of these claims submitted in the last 25 days. Indiana has 6,562 claims pending with approximately 15% of these submitted in the last 25 days. Of Kentucky's 3,069 claims pending, 88 of these claims are being developed for additional information other than whether Medicare is primary or patient eligibility. Of Indiana's 6,562 claims pending, 444 of these claims are being developed for additional information other than whether Medicare is primary or patient eligibility. Mr. Werfel feels that these figures demonstrate that AdminaStar has a handle on current claims.

REVIEWS: AdminaStar is still far behind in processing claim reviews. They have suggested that providers resubmit all requests for reviews and Fair Hearings as original claims. For claims that are more than one year old, AdminaStar's system will pay the claim less the 10% reduction for late submission. The 10% reduction will later be returned separately to the ambulance provider.

FAIR HEARINGS: The backlog for Fair Hearings is approximately nine months. Again, even if the provider has made a request for a Fair Hearing (and a Fair Hearing date has not been set) ambulance providers can and should resubmit the claim as an original.

REIMBURSEMENT ADVANCES: Four Kentucky ambulance providers have been considered for a reimbursement advance and three providers have been approved and received an advance. If any providers are in desperate financial straits and has a significant volume of claims tied up in the appeals process, they can apply for a reimbursement advance by contacting Lindy Lady for Kentucky providers and David Elliott for Indiana providers. However, reimbursement advances should not be requested unless the provider is truly desperate.

NEAREST APPROPRIATE FACILITY: AdminaStar and HCFA were advised that a number of providers where getting denials on claims where it was stated that the destination was not the nearest appropriate facility. Even if the transport was not the nearest appropriate facility, the entire claim should not be denied, rather the provider should be paid the base rate and mileage to what AdminaStar claims to be the nearest appropriate facility. Causes of this problem along with suggestions for resolution include:

• Diversions: When the first hospital is on diversion, the provider needs to list 'HOSPITAL ON DIVERSION' in the Narrative/Notepad record for electronic claims and with the description of the illness or condition on paper claims. It is suggested that the 'HOSPITAL ON DIVERSION' notation be listed at the beginning of the Narrative/Notepad record.
• Critical Access Hospitals: The increase in the number of Critical Access Hospitals is increasing the number of transports to distant hospitals. As above, the claim MUST document why the destination is now the nearest appropriate facility.
• AdminaStar's List of Hospital Services: The list of services available at specific hospital that is used by AdminaStar may be outdated. Providers should bring repetitive instances of incorrect denials to the attention of AdminaStar or through KAPA or the IAA.

LIST OF HOSPITAL SERVICES: AdminaStar advised that they will look into providing the American Hospital Association's listing that they use to determine the nearest appropriate facility to both KAPA and the IAA so that the providers can determine if the listing is outdated.

01/12/2001 DATE: AdminaStar reported that significant changes in claims processing became effective on 01/12/2001. Providers are requested to check their EOMBs for claims PROCESSED (go by the Julian date) after 01/12/2001. Any problems experienced by KY providers should be reported to Mike Swift at (270) 651-5122 and Indiana providers can contact Jerry Key at (812) 421-6500, Extension 304.

DUMMY ICD-9 CODE: AdminaStar has implemented a 'dummy' ICD-9 code for ambulance providers. The new 'dummy' code is 'AMB' and was provided so that electronic claims will not be denied for the lack of an ICD-9 code. NOTE: Medical necessity will still have to documented in the Narrative/Notepad record in order for the claim to be paid.

PATIENT CONDITION CODES: HCFA stated that AdminaStar has the discretion to use the new 'Patient Condition Codes'. It was suggested that AdminaStar adopt the 93 'Patient Condition Codes' listed in the 09/12/2000 Federal Register as proposed for use with the new National Ambulance Fee Schedule and use them in conjunction with the 'dummy' ICD-9 code listed above. For example, the first 'Patient Condition Code' would be AMB01, then AMB02, etc. AdminaStar advised that they would need to officially get the 'Patient Condition Codes' from HCFA and then determine whether they could be programmed into their current computer system. After that they would have to look at their adoption as part of a Local Medical Review Policy. Mr. Werfel suggested that KAPA and the IAA provide AdminaStar with a copy of the new 'Patient Condition Codes' and then request a meeting with AdminaStar's Part B Medical Director to start the process for developing the Local Medical Review Policy for Kentucky and Indiana.

DIALYSIS - MAINTENANCE PATIENTS: All parties understood the 'red flags' involved with dialysis and the current inconsistencies in payments to providers. It was suggested that AdminaStar use the 'diary' system so that all dialysis documentation is provided up front and the claims would be covered for a 30-60 day window, provided the patient's condition meets the medical necessity criteria. AdminaStar advised that they would look into this request and advise KAPA/IAA of their decision.

DIALYSIS - EMERGENCIES: It was brought to HCFA's and AdminaStar's attention that transports for emergencies other than dialysis were automatically being denied because the pick-up location was a dialysis facility. It was suggested that providers be allowed to use the 'S' (scene) modifier if the system would not interpret its use as a potential liability insurance. AdminaStar will research the suggested solution and get back with KAPA/IAA with a decision.

ROUND TRIP CLAIMS: Concerning round trip claims, Mr. Werfel requested that if (a) the transports do not cross a GPCI area; (b) do not originate in a rural area; and (c) do not cross a state border, providers be allowed to use the zip code for the origin of the first trip as if it were for both trips. The rationale for requesting this was to allow providers to bill the round trip on one claim, to allow AdminaStar to recognize the claim as a round trip, to allow AdminaStar to recognize and deny hospital in-patient round trips, and to allow AdminaStar to determine if SNF round trips should be paid. This will also prevent Medicaid and other third party payers from denying the second trip as a duplicate billing. HCFA advised that they would check with their central office to see if this could be allowed and will get back with KAPA/IAA.

NEW 'GX' MODIFIER: For transports that the ambulance provider wants AdminaStar to deny, they have implemented the new 'GX' modifier for use in the second position. The 'GX' modifier will auto-deny as a non-covered service. Requests for denials in the Narrative/Notepad record without the use of the 'GX' modifier may not result in a claim denial. This policy became effective 01/12/2001.

CODE A9270: AdminaStar will also check to see if the A9270 code has been implemented for non-covered services and will get back with KAPA/IAA.

IMPROPER PAYMENTS: In instances where the provider has requested a denial, but the claim was paid and the provider feels that the transport was a non-covered service, the provider should refund the payment to AdminaStar. With the implementation of the new denial code, this is more likely to occur on claims submitted prior to 01/12/2001.

CARRIER ADVISORY COMMITTEE: It was strongly suggested to both AdminaStar and HCFA that KAPA and the IAA be represented on AdminaStar's Carrier Advisory Committee for developing Local Medical Review Policies as well as any other policy changes involving ambulance providers. AdminaStar will get back with KAPA/IAA with a decision.

DUPLICATE DENIALS: AdminaStar advised that 47% of Kentucky's claim denials were for duplicate billings. The problem also exists in Indiana, but to a much lower extent. AdminaStar requested that KAPA and the IAA advise their members to refrain from routinely resubmitting claims as originals, UNLESS they are the claims now in review or appeal. This practice creates claims backlogs and delays providers from receiving their reimbursement.

Mr. Werfel indicated that if AdminaStar and HCFA implement all that was agreed upon at the meeting and if providers follow the suggestions noted above, most of the reimbursement problems would be resolved. KAPA and the IAA, though the help of their members, will continue to address other problems and issues as they develop along with monitoring AdminaStar's compliance to their agreements.