Recently, Dr Frank Delli Carpini, Carrier Medical Director (CMD) for Medicare, was interviewed by Judy Harris, Director of Compliance at the Yale Medical Group. Dr Delli Carpini, who is commonly referred to as "Dr D", provided the following insight in regards to the Medicare program in Connecticut.
Harris: You’ve been the CMD in Connecticut since April 2001. What were your biggest challenges in coming to Connecticut?
Dr D: My goal was to re-establish provider relations at First Coast and to be accessible to the provider community. The implementation of our new claims processing MCS, was also a major challenge for us. We at First Coast Service Options have a mission to be available and supportive to all providers and beneficiaries. The Office of the Medical Director is committed to accessibility and open communication to all our customers.
Harris: What can you tell us about the Progressive Corrective Action (PCA) audits conducted by Medicare?
Dr D: I am pleased that the process has an educational focus vs. a punitive overtone. Providers get selected for a PCA if their utilization statistics appear significantly different that their peers. FCSO usually reviews a sample of about 30 claims and then supplies feedback to the audited physician. Our provider community has been very pleased in all our efforts to educate them in regards to claims submission and medical necessity documentation. Our professional staff has enjoyed the opportunity to interact with our providers.
Harris: How can physicians become involved in the development of local medical policies?
Dr D: We generally ask specialty societies to comment on our draft policies and all physicians have the opportunity to comment on each draft policy for a 45 day time period. The draft policies are published on our web site and in our newsletters. Physicians should send their comments and suggested revisions with the appropriate reference to scientific literature to FCSO or their specialty society. All comments are researched and all accepted comments are then incorporated and published in the policy.
Harris: How can physicians become involved in the development of local Medicare policies?
Dr D: We generally ask specialty societies to comment on our draft policies and all physicians have the opportunity to comment on each draft policy for a 45 day time period. The draft policies are published on our web site and in our newsletters. Physicians should send their comments and suggested revisions with the appropriate reference to scientific literature to FCSO or their specialty society. All comments are researched and all accepted comments are then incorporated and published in the policy.
Harris: What are your particular concerns with medical services and claims to the Medicare program in Connecticut?
Dr D: CT’s utilization data is generally very good. We receive the top codes billed in our state and compare it to national norms. Over all our providers here in Connecticut have proven themselves to be very diligent and prudent in their medical services delivery.
Harris: What changes do you anticipate Medicare will make over the next few years?
Dr D: I think Medicare needs to establish clear parameters to look at coverage for new technology in a timely fashion.
Harris: What’s the status of the documentation standards for E&Ms? The latest reports are that new guidelines will be out in the 2005 CPT.
Dr D: Personally, I would like to see the process for selecting an E&M simplified. I think CMS is very receptive to listen to the proposals by the AMA CPT Work Group. CMS has allowed carriers to use an ‘inference’ process when determining what level of service the documentation represents. This allows our professional staff to use their vast knowledge base and correctly review and educate our providers.
Dr Delli Carpini can be reached at (203) 634-5410. The Medicare website can be found at http://www.fcsomedicare.com/