WG16 Property and Casualty/ Workers Compensation Meeting Minutes August 8, 2013

Transcription

1 WG16 Property and Casualty/ Workers Compensation Meeting Minutes August 8, 2013 Thursday, August 8, 2013 I. Welcome and Call to Order A meeting of WG16 Property and Casualty/Workers Compensation was held in Fort Worth, Texas on Thursday, August 8, Co-Chair Kevin Tribout of PMSI called the meeting to order at 1:31 p.m. and introduced Co-Chairs Brian Allen of Progressive Medical, Sandy Shtab of Healthesystems. II. Reading of the Antitrust Statement Kevin Tribout read the NCPDP Antitrust Statement. III. Housekeeping Items and Announcements Kevin Tribout reminded attendees that badges must be worn at all times; that cell phones and beepers should be set to vibrate or off; and that individuals wishing to make comments should wait for the microphone so they can be heard by all. He also noted that the attendance sheet is being circulated and asked that participants update their information if needed. Kevin provided the following information: 1. An update for the membership from the Board of Trustees will take place on Friday, August 9, 2013 from 7:30 8:00 a.m. (30 minutes) in Fort Worth Ballrooms Handouts are available for: a. August Work Group meeting schedule (sent via ; also available online) b. Work Group Attendee Roster (sent via ) c. Task Group Listing d. Calendar of Events (available online) Kevin asked first time attendees to identify themselves. There were four. He also requested that NCPDP buddies stand to be recognized and noted that they perform an important role in assisting new members to acclimate to the NCPDP processes. Kevin, as a member of the Strategic Planning Committee provided information on the activities of the committee in support of the new edvocacy focus of the organization. He presented an effort to document workgroup activities and initiatives to demonstrate how NCPDP and WG efforts contribute to quality, safety and cost savings outcomes. Members were asked to provide information on initiatives and/or need for actions to meet those objectives by October 1, See the SPC documents in the meeting download. IV. Agenda Sandy Shtab reviewed the agenda as modified by the Co-Chairs. Sandy announced that Kim Ehrlich of Express Scripts had assumed the leadership role for the Legislative/Regulatory Monitoring and Education Task Group and would be presenting the update. Sandy will continue to provide the IAIABC update that is listed with that task group. A motion was made and seconded to approve the agenda as amended. The motion carried. V. Minutes Sandy Shtab reported that the minutes of the May 2013 meeting were posted on the website for review. There were no corrections or additions. A motion was made and seconded to approve the minutes. The motion carried. WG16 Property & Casualty/Workers Compensation Page 1 August 2013

2 VI. Old Business A. Task Group Reports Attendees were advised to go to the NCPDP Collaborative Workspace at to join task groups and to obtain task group materials and schedules. 1. Legislative/Regulatory Monitoring and Education Task Group Kim Ehrlich of Express-Scripts Task Group lead provided the report. The presentation is available in the zip file on the Work Group 16 website at Meeting Minutes: August 2013 Presentations. Following is the discussion based on the presentation: California Senate Bill 146 eliminates the requirement under SB863 the Reform Bill for pharmacies to submit the original prescription with each bill. Delaware House Bill 175 based proposed rules apply a discount from the average wholesale price (AWP) of minus 12 (brand) and minus 20 (generic) percent and impose requirements for the underlying NDC for repackaged drugs and adoption of a preferred drug list or formulary. There was a hearing on the proposed rules on July 29, The Healthcare Advisory Panel met subsequently and voted to advance the rules as proposed. The rules are expected to become effective September 11, 2013 after publication in the state register. Florida Senate Bill 662 signed in June 2013, will require payers to base reimbursement on the original NDC of a repackaged drug. This is effective July 1, Dispensing physicians currently have to bill on the CMS1500 which is problematic for billing drugs because there is no place to put an underlying NDC. The DWC held a rules workshop on August 8, 2013, asking for public feedback and determined to continue with the CMS 1500 and bill both NDCs on the same line. The DWC will develop new EOB codes to clarify how reimbursement was calculated. The NCPDP WC/PC UCF was proposed by several stakeholders, but rejected as not a viable option because of the necessity for legislative action to make that change. It was pointed out that Florida has a different reimbursement formula for repackaged drugs from a pharmacy it is AWP plus a dispense fee, from a physician it is AWP plus 12 ½ percent and a higher dispense fee. Other states reimburse physician dispensed drugs with the same formula that they use for pharmacy dispensed drugs. This is why having the underlying NDC clearly documented on the bill is so critical to correct reimbursement calculations in Florida. Since Florida and other states are using the CMS 1500 it was suggested that the work group ask the National Uniform Claim Committee (NUCC) for a recommendation on how to report both the dispensed and underlying NDC on the CMS 1500 so that a standardized method can be defined. Idaho has implemented a fee schedule effective 7/1/2013 and is requiring that compounds be billed at the ingredient level. Also original NDC must be included for the physician dispensed repackaged drugs. Maine met to explore adopting a fee schedule, but have decided that a pharmacy fee schedule is not needed at this time. Oklahoma Senate Bill 1062 adopting a closed formulary was approved, but proposed rules have not yet been published for comment. From discussions it appears the rules will use the ODG guidelines. Comment was made that Pennsylvania is discussing workers compensation reform. From discussions they are looking to change the pharmacy program perhaps by imposing network requirements, formalizing the generic mandate, and/or revising the fee schedule. They have made it clear that they want to determine a way to do billing, perhaps electronically, and to address physician dispensing issues. Work on the reform bill is expected to start in September. It was also noted that as of September 1, 2013 the Texas closed formulary applies to all claims except the old law i.e., before January, 1, Treatment agreements must be in place before September 1. IAIABC Update: Sandy Shtab the NCPDP liaison to IAIABC informed the work group that the previously discussed webinar on compounds has been tabled. They are working with the WEDI Property and Casualty Work Group to do surveys on ICD10 preparedness. Additionally they are putting together WG16 Property & Casualty/Workers Compensation Page 2 August 2013

3 training on version 2.0 of their EDI guidance. An IAIABC liaison to NCPDP has not yet been named. IAIABC will be having their conference in October. Brian Allen volunteered to attempt to facilitate the naming of a liaison. Periodically IAIABC brings issues (e.g. the California second bill review question) to Sandy. It was noted that Mary Lynam the ASC X12 liaison to NCPDP had been approached by Sherry Wilson, ASC X12 liaison to IAIABC to close the loop. Sandy has been in communication with Sherry and requested that she send her any issues and requests for NCPDP assistance. So far there have been no new requests. One question did emerge regarding California s required use of the product strength field on the WCPC UCF. This field is not used in D.0 or the regular UCF. The Billing and State Reporting Task Group is drafting a letter to California to advise them that the field is not used in other sectors. 2. Billing and State Reporting Task Group Adam Fowler of PMSI, co-lead with Brian Allen of Progressive Medical and Kristie Griffin of Express Scripts provided the report. Task Group Recap Report Date: 7/15/13 Task Group Name: Billing & State Reporting Date Task Group Formed: August 2009 Task Group Leader(s): Brian Allen, Adam Fowler, Kristie Griffin Parent Work Group: WG 16 Property & Casualty/Workers Compensation Goal of Task Group: Evaluate and report on proposed/existing state reporting requirements impacting the pharmacy domain specific to workers compensation and property & casualty. Educate, and attempt to synergize policy makers and policies to utilize NCPDP standards for billing and state reporting on pharmacy claims. Task Group Meeting Dates (This Period): None (though leadership call on 7/15/13) Business Cases Reviewed: Discussion on California SB 146 held on 7/15/13 leadership call. Reviewed if NCPDP request for guidance to California Division of Workers Compensation needed for how to treat resubmitted bills for bills originally denied based on lack of prescription copy. Task Group Decisions (bullets or text): Final draft version of guidance document submitted to standardization co-chairs for review Made final edits to guidance document based on standardization co-chairs recommendations DERF submitted to update jurisdictional field assignments in UCF reference for brand/generic selection Task Group Reportables (bullets or text): Legislative/regulatory changes related to billing and state reporting will be reflective in the task group s quarterly slide updates. Task Group Questions to the Work Group (bullets or text): Would like to discuss state outreach letters after finalization of updated guidance document Task Group Action Items/Next Steps (bullets or text): Finalize and send out survey on reconsideration bills Support approval and finalization of DERF to update jurisdictional field assignments in UCF reference for brand/generic selection. The presentation is available on the Work Group 16 web page in the zip file at Meeting Minutes: August Presentations. Adam noted that some of the content was covered during the Legislative/Regulatory Monitoring and Education Task Group discussion. There was intent to reach out to California for clarification of whether the bills resubmitted secondary to denial for lack of original prescription were to be treated as original bills or reconsideration bills. After discussion the task group concluded that most payers were not denying the bills and so it was a non-issue. Any that might have been denied must be resubmitted by March 31, California has not completed their proposed reporting penalty regulations, but are considering moving to the IAIABC reporting standards based on ASC X transactions and therefore supportive of ICD10. Florida has a monetary threshold that applies if they try to introduce a new rule or modify an existing one. If there is an impact of 1 million dollars they must have legislative ratification. Most WG16 Property & Casualty/Workers Compensation Page 3 August 2013

4 of the items attempted in recent years, fee updates, changes to maximum allowable, etc. have not been approved. Illinois has mandated electronic billing for payers effective June 30, 2013 based the IAIABC standard, however no rule has been adopted and no companion guide has been published. This was adopted by the Department of Insurance rather than the Workers Compensation Commission. Louisiana requirement for payers to accept electronic billing was effective July 1, It does not apply to self-insured plans. Oregon Medical ebilling Advisory Committee is still meeting in preparation for proposed rules. The August 19 meeting has been postponed to September 19, They have been very responsive to comments brought forward in the committee meetings. A suggestion was made to ask for someone from Oregon, perhaps Fred Bruyns, to present on their electronic billing development at the next meeting in Portland. They have a hard date of April for reporting using the IAIABC Release 2/ASC X format for all services reported on or after that date. Arizona just completed action on their 2013 fee schedule which will go into effect this fall. They are to look at adopting a standard billing format for pharmacy. They are going to be setting up a work group to work on the issue. Members were encouraged to participate in the discussions. The Director, Laura McCrory reached out to various stakeholders. Support is needed from the pharmacy community. They do not have any electronic billing rules at this time. California had approached NCPDP for help in identifying a bill being submitted for second bill review in both the electronic and paper formats. There is no mechanism in the electronic format to identify these bills. After discussion it was decided that NCPDP should establish the extent of the requirement in workers compensation and whether the development of a standard solution was justified. To this end a survey was constructed. Subsequently, because of the level of effort involved in an electronic solution, the survey was revised to include the requirements, if any, of a wider range of stakeholders. A part of the survey is aimed at determining what additional information, not conveyed in the bill itself, is needed to complete the process and whether this information can be standardized. The plan is to send it to the state jurisdictions as well as payers and processors in all sectors. A motion was made and seconded to approve the survey. The motion carried. B. Guidance Document Update Sandy Shtab informed the work group that the Guidance Document had completed the approval process and has been published. It is available to the public at C. epa in Workers Compensation Factsheet Sandy Shtab reported that there was a sub-task group formed in Work Group 11 to put together talking points for legislators regarding the NCPDP Electronic Prior Authorization Standard. Members from both WG16 task groups participated in the calls. There were some challenges to gaining consensus that were unrelated to workers compensation. Initially it was thought that some language might be included to the effect that epa might not be appropriate to all payer situations, specifically in the property casualty realm. The participating members decided to not pursue further action at this time, but will continue to monitor the effort. D. Billing Issues 1. Colorado Compound Codes This discussion was deferred until DERF is reviewed. 2. WC Claim Adjustment Reason Codes (CARC)/Remittance Advice Remark Codes (RARC) Brian Allen reported that IAIABC is requesting the creation of new RARCs for use in workers compensation and property and casualty. There are a limited number of CARC and RARC codes available for pharmacy. In Oregon there is a push by some parties to develop some state specific codes that will complicate processing for any entities not working exclusively in Oregon. The discussion with IAIABC is indicating a desire on their part for this work group to provide information of any gaps with the current codes approved for pharmacy because they feel the codes are not adequate. Brian asked work WG16 Property & Casualty/Workers Compensation Page 4 August 2013

5 group members to submit information about the limitations to the current remittance advice messages and any messages they would like to see added. Margaret Weiker informed the group that the IAIABC has endorsed the ASC X12 TR2 for CARCs and RARCs. NCPDP WG45 deals with the CARCs and RARCs as implemented in pharmacy and in the CAQH CORE Operating Rules. She recommended that WG16 take any identified CARC/RARC needs for workers compensation or property and casualty pharmacy to WG45 for their assistance in moving them through the process. IAIABC is taking all the state specific codes to the ASCX12 TGB WG3 for consideration for use in the ASC X A special sub group of that work group is being established to review the possibility of establishing a new external code set for property and casualty that would be referenced like the NCPDP Reject Codes. The process and procedures for requests and maintenance are being worked out. They have also submitted code requests to the respective code committees, but most were rejected because they were too specific. This is one of the reasons that it is important that members engage with the regulators to try to move them to the use of standards. 3. Identification of Reconsideration Bill See the Billing and Reporting Task Group report for a discussion of the reconsideration bill and issue survey. VII. New Business A. New DERF Review Kevin Tribout presented DERF which requests Modify the Jurisdictional Field Assignments to reflect the current state requirements: Remove Kansas and Rhode Island from the multi-state assignment at and replace with Alaska, Maine and Oregon KANSAS, ALASKA, KENTUCKY, MAINE, MONTANA, NORTH DAKOTA, OHIO, RHODE ISLAND, OREGON, TENNESSEE, VERMONT, WEST VIRGINIA, WISCONSIN, WYOMING Populate the Jurisdictional fields for Generic Equivalent Product ID only when the Patient opts to obtain the Brand medication and pay the cost difference between the Brand and Generic. In the Pricing Section, the Net Amount Due is based upon the generic equivalent. In this situation, the payer is only liable to pay for the cost of the generic medication even though the patient received the brand. These are changes that were identified during the review and update of the Guidance document. There was a discussion regarding moving this to an external code set to avoid having to complete a DERF and redo the WC/PC Manual Claim Form Reference Guide every time there is a change. A suggestion was made that it could perhaps be handled as an FAQ. If a cross reference is created it would have to be tightly coupled to the Guide, perhaps by packaging both in a zip file to provide to purchasers of the form. There have been problems with people not using the right form with the right version of the guide because the regulation says one version but the guide has been updated. If the change is made going forward how will it be communicated to existing users? How would the time frame for implementation to be maintained? The issue will be deferred for closer examination. Sandy Shtab reminded attendees that Colorado had changed their rules 3 years ago to require the use of state specific Z codes to define compound categories that define the maximum reimbursement for the compound as a means to control costs. In recent discussions with the Colorado Department of Workers Compensation they have agreed to adopt the WC/PC UCF as it will allow for the capture of all the ingredients in the compound for analysis of the cost effectiveness. Use of the form will be phased in becoming mandatory in next year s rule. To this end the DERF was modified to assign a Colorado Jurisdictional field to report the state defined compound codes. The following modification was added to the DERF request: 08/08 - Based on new developments with the state of Colorado a motion was made to modify the request to add a Jurisdiction Field assignment for CO to address the need to report state defined codes for compounds x COLORADO Populate the Jurisdictional field for state specific compound category code as defined in the WG16 Property & Casualty/Workers Compensation Page 5 August 2013

6 WC/PC UCF Field Colorado Workers Compensation Fee Schedule regulations in effect on the date the service/product was rendered/dispensed. 60 State Specific Compound Code A/N 5 NCPDP Field NA The current categories and codes are: Z0790 Category I - Any anti-inflammatory medication or any local anesthetic single agent. Z0791 Category II - Any anti-inflammatory agent or agents in combination with any local anesthetic agent or agents. Z0792 Fee Category III - Any single agent other than anti-inflammatory agent or local anesthetic, either alone, or in combination with anti-inflammatory or local anesthetic agents. Z0793 Category IV - Two or more agents that are not anti-inflammatory or local anesthetic agents, either alone or in combination with other anti-inflammatory or local anesthetic agents. The following language was added to the WC/PC UCF Manual Claim Forms Guide: X COLORADO Populate the Jurisdictional field for state specific compound category code as defined in the Colorado Workers Compensation Fee Schedule regulations in effect on the date the service/product was rendered/dispensed. Name Definition Type Length NCPDP Field ID 60 State Specific Compound Code State defined code A/N 5 NA A motion was made and seconded to approve the DERF as modified to address the new request. The motion carried. B. DSMO Change Request There were no DSMO change requests for review by the work group. C. Work Group Scope and Goals Brian Allen presented the scope and goals as amended by the co-chairs. The changes are noted in bold. WG16 Property and Casualty/Workers Compensation Work Group 16 Property and Casualty/Workers' Compensation will ascertain, monitor and analyze regulatory requirements to develop correlating fields to be supported in the Telecommunication Standard format; evaluate, and maintain a Property and Casualty/Workers Compensation standard paper claim form; proactively promote and educate pharmacy industry stakeholders and regulatory policy makers on the form and format standards found in Property and Casualty/Workers Compensation (including but not limited to uniform billing, state reporting policies and the overall delivery of pharmacy services/care). Goals: 1. Promote NCPDP membership attendance and active participation in work group meetings. 2. Promote open and active participation by Work Group members in educating policy makers on issues pertinent to the delivery of pharmacy care/services for Workers Compensation/Property and Casualty patients. 3. Support outreach efforts through sponsoring presentations by policy makers/regulators and/or industry experts at work group meetings. 4. Develop electronic claim solutions for current and future needs, within the Workers Compensation/Property and Casualty industries, not addressed in the NCPDP Telecommunication Standard Implementation Guide. WG16 Property & Casualty/Workers Compensation Page 6 August 2013

7 5. Promote a national standard for pharmacy billing and reporting to Property and Casualty/Workers Compensation policy makers and stakeholders. 6. Seek and promote solutions between stakeholders that may currently lack visibility and/or understanding about the pharmacy fulfillment and billing processes as it pertains to Workers Compensation/Property and Casualty. 7. Modify the existing WC/PC Universal Claim Form and Reference Guide and NCPDP electronic standards (formats), as needed, for the Workers Compensation/Property and Casualty industries. 8. Review and analyze current NCPDP standards which impact the Workers Compensation/Property and Casualty industries and develop action plans or modify NCPDP formats to meet the needs of the Workers Compensation/Property and Casualty industries. 9. Collaborate with other NCPDP work groups and the International Association of Industrial Accident Boards and Commissions (IAIABC) as needed. 10. Monitor the task groups to ensure they are on track to complete their work. If appropriate, disband task groups that have completed their work. 11. Support the MC Education Legislation-and Regulation Task Group when new legislation is being introduced regarding issues relevant to the work group. For a list of acronyms, please see A motion was made and seconded to approve the Scope and Goals as amended. The motion carried. D. Next Quarterly Work Group Meeting The next NCPDP quarterly work group meeting will be held on November 6-8, 2013 at the Portland Marriott Downtown Waterfront, Portland, OR. Brian Allen prepared the proposed agenda for the next meeting: Old Business Task Group reports Legislative/Regulatory Monitoring and Education TG Billing and State Reporting TG DERF follow-up IAIABC Update Billing Issues Follow-up Discussion CARC/RARC Follow-up Reconsideration Bills Follow-up WG16 Scope and Goals Reportable New Business New DERF (if necessary) DSMO Change Requests (if necessary) Possible Guest Presentation Oregon DWC Externalization of Jurisdictional codes WG16 asked for ½ day, if possible Wednesday afternoon, and to not conflict with WG45. It was moved and seconded to approve the proposed agenda. The motion carried. E. Educational Program The next Educational Program will be Aligning Healthcare to Improve Patient Safety: NCPDP is More than Claims and Billing! at the Portland Marriott Downtown Waterfront, Portland, OR on Wednesday, November 5, F. Submission of new DERFs Submission of new DERFs and Project Development Forms is due Monday, October 7, 2013 to Kittye WG16 Property & Casualty/Workers Compensation Page 7 August 2013

8 Krempin (if necessary). VIII. Motion to Adjourn Kevin Tribout asked for a motion to adjourn the meeting. The motion was moved and seconded. The motion carried. The meeting adjourned at 4:39 p.m. Attachment (available on the website or by contacting the Council office): Attendee Roster Proposed Agenda Presentations Sue Thompson Staff Liaison WG16 Property & Casualty/Workers Compensation WG16 Property & Casualty/Workers Compensation Page 8 August 2013