The Academy has been extremely concerned about the issues members have raised with regard to the Palmetto transition. This special issue of Practice Management News, which offers advice about dealing with Palmetto, is one response.  We have also contacted officials from both the CMS Region IX office and Palmetto. CMS agreed to directly accept calls from family physicians who have been unable to appropriately resolve Medicare Part B issues with Palmetto. In addition, Palmetto officials have agreed to host a WebEx exclusively for Academy members to get their questions answered. The WebEx is scheduled for Thursday, Oct. 23, 2008 from 12:30 - 1:30 pm. Registration will be required; more information will be available on our Web site homepage (http://www.familydocs.org/). In addition, Academy staff will continue to monitor Palmetto's progress toward improving customer service and provide timely member updates. If you are having difficulty getting assistance with your issue from Palmetto GBA and are not able to participate in the WebEx, here's what you need to do:

• Call the San Francisco Regional CMS Office at (415) 744-3658.
• The secretary will do an intake and start the process to get the issue addressed by Palmetto GBA.

Frustrated with California's New Medicare Contractor?
Try These Tips for Effectively Communicating with the New Contractor

Palmetto GBA recently won the contract to become the Jurisdiction 1 Medicare Administrative Contractor (MAC). On Sept. 2, 2008, California Part B (known as segment 3) transitioned to Palmetto. While Palmetto planned for the transition months in advance and tried to prepare physician practices for the changes, many physicians and their office staffs have encountered significant frustration in dealing with the new carrier. This can be attributed to a number of factors. First, Palmetto was not prepared to handle the volume of concerns from California physicians. This resulted in many physicians' inability to get through by telephone to speak to a representative. A number of technology issues and other glitches resulted in delayed payment and other issues. In addition, the volume of incomplete items Palmetto received from its predecessor (NHIC) was both significant and unexpected. Finally, some physician offices did not appropriately prepare for the transition.

No matter the reason for the frustration, each practice must get a handle on outstanding issues promptly to assure that Medicare claims and issues are resolved effectively and practices are not adversely affected - financially or otherwise. Use the following tips to help navigate the various systems at Palmetto GBA to resolve your issues and, hopefully, minimize your frustration!

1. Use the Internet: Palmetto's primary means of communication is the Internet.  You should have at least one person from your practice registered for the Palmetto GBA listserv. If you haven't signed up, do it now! Go to www.palmettogba.com/j1b and select "email updates" on the top banner. You will need to create a username and password; you can select the types of documents you want to receive. The listserv provides updates of recent issues and changes in policy as well as notices of upcoming educational meetings and seminars. You can also comment on Palmetto policies and receive links to a number of CMS tools. 

2. Check the Web site BEFORE Calling: There is no waiting required to access the Web site and it is available 24/7. The address that takes you directly to the J1 Medicare Part B site is: www.palmettogba.com/j1b. Learn to use the J1 Web site as a primary resource for Medicare claims issues, billing guidelines, local coverage determination policies, modifier look-ups, bundling edits and other educational resources. On Oct. 14, 2008 at 12:30 pm, Palmetto will host a webinar on "Navigating the Web site." You can learn about available Web site features, including resource tools and how to access follow-up information, should you need it. Encourage your office staff to participate in the free webinar.  All practices that have signed up for the listserv will receive registration information (registration is required in order to access the event). 

Some of the helpful Self-Service Tools for family physicians on the Web site are:

Alerts: This is a chronological listing of the latest issues that have been brought to Palmetto's attention. The goal is to assist you in resolving possible claims denial issues. The following is an example of a recent issue affecting a number of family physicians: 

• Vitamin B12 Injections: Procedure code J3420 (Vitamin B12) was denied in error. Policy L28315 (dates of service on and after 9/2/08).
• Remark/Reasons Codes: 50 and N155.
• MAC Action: A mass adjustment will be performed to correct claims denied in error.
• Provider Action: No action required.
• Date Reported:  Sept. 22, 2008

If you received a B12 injection denial and checked the alerts instead of trying to call Palmetto, you would have known immediately that the claims adjudication problem had been resolved, eliminating the need to take further action.

Interactive CMS 1500 Claim Form: While most practices submit claims electronically, this tool can still be helpful if you have questions or concerns about any difference in claims submission guidelines between NHIC and Palmetto.  The tool is interactive; click on any field on the CMS 1500 claim form, it will detail what needs to be in that particular field. 

Interactive Voice Response (IVR) Job Aids: Unlike NHIC, Palmetto's IVR is NOT voice-activated. Because Palmetto is working on a new automated system that will be available online, there are no plans to make the IVR voice-activated.  The job aids are helpful while learning to use the current system, however. As with any new system, it takes a little practice to become proficient.  

J1 A/B MAC Transition Web Site: If you are looking for addresses and phone numbers, this is the place to find them. This link takes you to a listing of all important phone numbers and addresses. 

Modifier Look-Up: As you know, modifiers often cause claim denials and payment delays. To add to the confusion, Palmetto may handle some modifiers differently from NHIC. Use Palmetto's modifier look-up tool to ensure your modifier use conforms with Palmetto's policy. 

Fee Schedules: Palmetto's fee schedule listing has a different format from NHIC. Instead of one document for each payment locality in California, the entire state has been consolidated into a single document. It is broken up by payment locality, however, and you can scroll down until you find the particular location for which you are searching. You can directly access the particular locality you are searching for on the left-hand "table of contents" to better navigate to your desired location. 

Forms: All the forms you will need should be here. This includes ABNs, appeals, provider enrollments, fax cover sheets and overpayment refund forms. 

3. Calling the Provider Contact Center (PCC): This has been, without a doubt, the most frustrating of all issues. Immediately post-transition, the PCC received 3,000 calls a day and the IVR received 13,000 a day! To relieve the situation, Palmetto requested permission from CMS to install an additional 35 phone lines and to add appropriate staff. That remedy is being implemented at this time. The first few groups of new employees have completed training and have been assigned to the phone lines. It has been reported that the average wait time has dropped in the past few weeks from more than one hour to approximately 40 minutes. The PCC call hours are 7 am - 5 pm. While the beginning of the day is a peak time for calls, the standard lunch hour and near the end of the day (4:15 - 4:45 pm) appear to have shorter wait times. During the last Transition Advisory Group (TAG) meeting, Palmetto reassured the group they were striving to reduce the average PCC wait time to less than two minutes. It is likely this will take several more months.

Additionally, many of the PCC calls were claims-related issues that could be resolved by accessing the IVR or checking the Web site for the latest alerts. To minimize your wait time with the PCC, check those two resources first!

Finally, many of the PCC calls are issues related to one of the two special projects NHIC failed to complete. This includes the Code Option Project and the NPI issue project. To alleviate the stress on the PCC, a separate direct phone number ((866) 895-1520) has been installed for these two provider enrollment issues. Hours of operation are 8 am - 4 pm.  

4. Monitor Your Payments: Many physicians are concerned about Medicare payment delays. Consider these two issues before deciding what the best course of action will be for you:

1. On 8/18/08, the payment floor (the mandatory 14- or 21-day hold on payment after claims processing) was cleared to allow the previous contractor (NHIC) to pay the majority of the claims submitted before the transition. This means that your practice probably received a larger volume of Medicare payments between that date and the end of August.  The payment floor was then re-applied on 9/2/08. This meant that for the first two weeks of September, most practices had a much smaller volume of Medicare payments coming in since they had already been paid. This was alarming, even though many practices had received larger Medicare payments by the end of the previous month.
   
2. Many payment issues still revolve around the Option Code and NPI projects that NHIC began. Many applications have now been with Palmetto for a long time (and meanwhile, you aren't getting paid). If you submitted an application to NHIC (which has now been transferred to Palmetto) more than 90 days ago, call NOW and request that your application to be expedited. Call the new direct number for provider enrollment - (866) 895-1520 - to make that request. Please note that your 13-digit reference numbers must be assigned to each of your 855 applications. 

If you are experiencing a significant financial hardship because of one of the projects listed above, you may be eligible for an advance payment from Medicare. Requests for advance payment should be faxed to:

J1 MAC - Palmetto GBA
Attn: Vicky Bowers AG-325
"MSC J1-4084"
17 Technology Circle
Columbia, SC 29203-9591
Fax:  803-763-5575

The request must be on practice letterhead and signed by an authorized person. It must include the reason your cash balance is seriously impaired, along with financial information to show hardship. Complete instructions for requesting advance payments can be found on Palmetto's Web site under the "News" link on the right of the J1 MAC home page. Palmetto must submit the request to CMS for its approval before advancing the payment. 

5. Exercise Patience: Patience can be a challenge when the frustration level is at an all-time high. But as with most administrative changes, kinks need to be worked out. The last few weeks have been extremely frustrating for many family physicians; however, it appears that the worst is behind us. 

When you call the PCC, realize it will take 30-40 minutes to reach someone and when you do, he or she may not be able to resolve your issue immediately. It does no good for you to tell such staff what a horrible job they are doing and how you wish NHIC was still the contractor. Think about how you react when confronted by an angry patient - anger usually gets us nowhere fast! You will be more effective and will have a much better chance of garnering support from the customer service representative if you simply state your facts, ask for assistance in resolving the issue and ask when you can expect resolution.  

Remember the Following:

• Sign up for the listserv to receive the latest information and updates.
• Use the Web site for problem resolution before calling the Provider Contact Center.
• Call the Regional CMS office at (415) 744-3658 if you are not getting assistance with your issue from the PCC.
• Make sure you have completed all the paperwork required for the transition (this includes the EDI enrollment, EDI agreement and EFT agreement).
• Set aside specific times of the day to work on your Medicare issues, understanding it will take a while.
• Maintain your patience for your patients - because that is what this is all about!

Mary Jean Sage has extensive experience in the healthcare field spanning a period of more than 20 years during which time she has managed diverse groups of professionals in delivering patient care.  A founding Principal and Senior Consultant with The Sage Associates, Mary Jean is a nationally-known speaker, consultant and educator. 

DISCLAIMER

The articles provided in Practice Management News are general.  They do not constitute legal, practice management or coding advice in any particular factual situation or create an attorney-client relationship.  Consult your attorney or other professional for advice in your particular situation.