cahaba gba’s 2014 medicare expo august 7, 2014 chattanooga, tn provider contact center (pcc)...

Cahaba GBA’s 2014 Medicare Expo

Cahaba GBA’s 2014 Medicare Expo

August 7, 2014August 7, 2014Chattanooga, TNChattanooga, TN

Provider Contact Center (PCC)Provider Contact Center (PCC)

Presented by Renea Cloud

Provider Outreach and Education

As directed a copy of the presentation is available for viewing or download on the Cahaba GBA website

DisclaimerThis resource is not a legal document. This presentation was prepared as a tool to assist our providers. This presentation was current at the time it was created. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services.

Reproduction of this material for profit is prohibited.

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Agenda• Cahaba GBA Mission Statement• Provider Customer Service Program (PCSP)• Customer Service Representatives (CSRs) • Provider Inquiry• Provider Inquiry Calls• Inquiry Resolution Strategy

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Our Mission:

To provide best value solutions that improve healthcare administration

Charting Our CourseCharting Our Course

Cahaba GBA Mission Statement

5http://www.cahabagba.com/

Our Values:• Integrity• Customer First• Teamwork• Innovation• Continuous Improvement

Charting Our CourseCharting Our Course

Cahaba GBA Mission Statement

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PCSP Organizational Chart

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Director of Director of OperationsOperations

Provider Services Provider Services Departmental Departmental

ManagerManager

Provider Provider Outreach & Outreach & Education Education ManagerManager

Provider Provider Contact Center Contact Center

ManagerManager

Customer Service Customer Service RepresentativesRepresentatives

Provider Outreach & Education Consultants

Part B Part B EntitlementEntitlement

Part A Part A EntitlementEntitlement

Part A Part A EntitlementEntitlement

Part B Part B EntitlementEntitlement

Written Written Inquiry/Clerical Inquiry/Clerical

Error Error Reopenings Reopenings

ManagerManager

Electric Data Electric Data Interchange Interchange

ManagerManager

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/com109c06.pdf

• Centralized office for the purpose of receiving a large volume of requests by telephone to provide customer service and technical support to Medicare providers– Respond to inbound provider customer calls– Research and resolve a wide variety of customer questions and issues– Ensure information given is timely and accurate– Accurately and promptly document all calls

Provider Contact CenterProvider Contact Center

Provider Customer Service Program (PCSP)

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Medicare Contractor Beneficiary and Provider Communications Manual 100-09Chapter 6 – Provider Customer Service ProgramSection 30 – Provider Contact Center (PCC)

http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/com109c06.pdf

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• Qualifications for CSRs:– Experience in Customer Service requiring problem solving– Ability to understand and interpret complex oral and written directions– Ability to multi-task– Experience research information

The IndividualThe Individual

Customer Service Representatives (CSRs)

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• Comprehensive Training Program:– Introduction to Medicare– Guideline Manuals– Fiscal Intermediary Standards System (FISS)– Multi-Carrier System (MCS)– Call Center Simulation– LIVE Call Center Observation– LIVE Call Center Log-in with Conference Supervision

CSR TrainingCSR Training

Customer Service Representatives (CSRs)

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Continued EducationContinued Education

Customer Service Representatives (CSRs)

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http://www.cahabagba.com/contact-us/

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• Contact Us:– Write– Email – Phone

Contacting Cahaba GBAContacting Cahaba GBA

Provider Inquiry Calls

15http://www.cahabagba.com/contact-us/

• Categories of Telephone Inquiry:1. Interactive Voice Response (IVR) System2. Level I – Customer Service Representative3. Level II – Customer Service Representative4. Escalated Provider Inquiry

Telephone Inquiry Classification ProcessTelephone Inquiry Classification Process

Provider Inquiry Calls

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• CMS Internet Only Manual (IOM) Chapter 6 Section 50.1:“Providers shall be required to use IVRs to access claim status and beneficiary eligibility information. CSRs shall refer providers back to the IVR if they have questions about claims status or eligibility that can be handled by the IVR. CSRs may provide claims status and/or eligibility information if it is clear that the provider cannot access the information through the IVR because the IVR is not functioning.”

Interactive Voice Response (IVR) System Interactive Voice Response (IVR) System

Provider Inquiry Calls

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http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/com109c06.pdf

IVR MappingIVR Mapping

Provider Inquiry Calls

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• Ability to view:– Prompt Entry

– Prompt Option Completion

Provider Contact Center Call VolumeProvider Contact Center Call Volume

Provider Inquiry Calls

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Part A Calls:•23,158

Part B Calls:•117,217

June Call Total:•140,375

Daily Call Average:•4679

• Answer a wide range of basic questions that can not be answered by the IVR or other interactive self-service technology

• Questions that do not require substantial research and answered during the initial call

• If inquiry can not be answered, referral to second level CSR

Level 1 – Customer Service RepresentativeLevel 1 – Customer Service Representative

Provider Inquiry Calls

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http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/com109c06.pdf

• Authentication Requirements

• Protected Health Information (PHI) disclosure guidelines

Disclosure Desk Reference GuideDisclosure Desk Reference Guide

Provider Inquiry Calls

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http://www.cms.gov/Medicare/Medicare-Contracting/FFSProvCustSvcGen/Contractor-Resources.html

• More complex inquiries requiring high levels of research

• Allow 10 business days from initial call for review

• If inquiry can not be answered, an escalated provider inquiry is submitted for review

Level II – Customer Service RepresentativeLevel II – Customer Service Representative

Provider Inquiry Calls

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http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/com109c06.pdf

• Complex provider inquiries only

• Provider Relations Research Specialist

• Complex inquiries regarding coverage policy, coding, and payment policies

• Substantial research is required

Escalated Provider InquiryEscalated Provider Inquiry

Provider Inquiry Calls

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http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/com109c06.pdf

June Top Phone Inquiry StatsJune Top Phone Inquiry Stats

Provider Inquiry Calls

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• Research Perimeters:– 5 Day Call Research/1.5 Hour Time Frame– Incoming Provider Calls (Part A & B)– Call Reason/Question– Caller Preparedness– Caller Etiquette– Call Resolution

Provider Call ResearchProvider Call Research

Inquiry Resolution Strategy

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• Findings:– 83 Calls Received

• 99 Separate Inquiries – Call Inquiry Rate of Return 119%

Research AnalysisResearch Analysis

Inquiry Resolution Strategy

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Research AnalysisResearch Analysis

Inquiry Resolution Strategy

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Research AnalysisResearch Analysis

Inquiry Resolution Strategy

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• Provider Call Research showed:– 47% of callers unprepared at time of contact with CSR

• Review of Unprepared Callers showed:– Missing required information to appropriately disclosure requested information

• Did not have/know appropriate PTAN/NPI/Tax ID• Invalid Beneficiary Information• Invalid Information Entry into IVR• Denial Reason from Remittance Advise• Claim Validation Information• Reference ID Information• Check Numbers/Remittance Numbers

Develop a Call Contact PlanDevelop a Call Contact Plan

Inquiry Resolution Strategy

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Hi, I am calling about……

– Claims Denial

– Claims Status

– Beneficiary Eligibility

– Appeal Status

– Provider Enrollment Question/Status

– Revalidation Question/Status

– Overpayment Recovery

– Refund Status for Overpayment

Provide Inquiry ReasonProvide Inquiry Reason

Inquiry Resolution Strategy

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• Gather all essential information regarding your inquiry, be ready to provide additional information– NPI/PTAN/Tax Id

– Reference Number(s)

– Beneficiary Information

– Claim Information

– Remittance Advice Information

Provide Additional InformationProvide Additional Information

Inquiry Resolution Strategy

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• A call reference number is the call segment identification information– Example:

• GINQ

• REVAL

• FINSV

• APPL

Attain a Call Reference NumberAttain a Call Reference Number

Inquiry Resolution Strategy

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• Cahaba GBA Website provides multiple self-help tools to assist providers in their research– Claim Issue Log

– Claim Submission Error (CSE) Log

– Frequently Asked Questions (FAQs)

– Check Status of Provider Enrollment

& Revalidation Applications

– Check Appeals Status

– Check Eligibility & Claims Status

Self Help ToolsSelf Help Tools

Inquiry Resolution Strategy

34https://www.cahabagba.com/

• CMS Website provides multiple self-help tools to assist providers in their research– Internet Only Manuals (IOMs)

– National Correct Coding Initiative Edits

– Medicare Coverage Database

– Latest ICD-10 Transition Information

Self Help ToolsSelf Help Tools

Inquiry Resolution Strategy

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http://www.cms.gov/

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Website Navigation AssistanceWebsite Navigation Assistance

Cahaba GBA Website Kiosk

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• Live Onsite Assistance

• Available Stations in Designated Area

• Consultants Available to Assist with Website Navigation

• Answer Questions Pertaining to Finding Medicare Information

• ForeSee Survey

http://www.cahabagba.com/

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Resources

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Cahaba Government Benefit Administrators • http://www.cahabagba.com/

Centers for Medicare and Medicaid Services• https://www.cms.gov/icd10/

Centers for Medicare and Medicaid Services Regulations & Guidance• http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-

IOMs.html

Medicare Coverage Database• http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx

Washington Publishing Company• http://www.wpc-edi.com/reference/

Question and Answer Session

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Provider Contact Center 1 (877) 567-7271

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