Provider-Based Rural Health Clinics

1. Provider-Based Rural Health Clinics Charles A. James, Jr. President and CEO North American Healthcare Management Services www.northamericanhms.com 888.968.0076

2. Overview • Definitions • Reimbursement Comparison • Provider-based Criteria • Attestation and OCR • Hospital Considerations www.northamericanhms.com 888.968.0076

3. Definitions PPS - Prospective Payment System: a Medicare payment system for short-term acute care hospitals. CAH – Critical Access Hospitals: receive Medicare payments at 101% of reasonable costs. (Lay term: RHC program for hospitals) www.northamericanhms.com 888.968.0076

4. Definitions Provider-based Rural Health Clinic (PBRHC): an RHC which is owned and operated by a parent-entity. Usually a hospital. A PBRHC whose parent entity is less than 50 beds is eligible for an un-capped encounter rate. www.northamericanhms.com 888.968.0076

5. RHC Reimbursement Currently, independent RHCs are capped at $79.80 for 2014. The average provider-based RHC encounter rate (that we see!) is between $140.00 – 167.00. www.northamericanhms.com 888.968.0076

6. Medicare Reimbursement Comparison www.northamericanhms.com 888.968.0076

7. Provider-Based RHC Payments PBRHC Attached to CAH or PPS < 50 Beds: $$ = Uncapped Encounter Rate PBRHC Attached to PPS > 50 Beds: $$ = Current Medicare RHC Cap www.northamericanhms.com 888.968.0076

8. NON-RHC Provider-Based Clinic • Non-RHC, Provider-based clinic maintain a dual billing/payment structure. • A facility component is billed on the UB04, using the hospital provider number. • Professional services are billed on a 1500 and place of service 22. www.northamericanhms.com 888.968.0076

9. NON RHC Provider-Based Payment • Facility Payment: • PPS – APC Method • CAH – 101% of allowable costs • Professional Services Payment: • PPS – Physician Fee Schedule (Facility) • CAH – Physician Fee Schedule (Facility) • CAH Method II – 115% Physician Fee Schedule www.northamericanhms.com 888.968.0076

10. Diagnostic Testing and Lab: Provider-Based The professional component for X-Ray, EKG, and other diagnostic testing is bundled with the RHC encounter. The technical components for X-Ray, EKG, ultrasounds, etc. are billed to the FI using the parent entity’s provider number. Lab services are also billed to the FI using the parent entity’s provider number. www.northamericanhms.com 888.968.0076

11. Provider-Based Requirements Provider-based clinics are governed by CMS Program Memorandum A-03-030. This document delineates requirements for on-campus and off-campus (more than 250 yards from hospital campus) PB clinics. www.northamericanhms.com 888.968.0076

12. Provider-Based Attestation Compliance with provider-based requirements is reported to the Medicare Administrative Contractor via ‘Provider-Based Attestation’. www.northamericanhms.com 888.968.0076

13. On-Site PBRHC Provider-based attestations will not be accepted or reviewed for the following two situations: When the entity is located on the floor of the main building/department of the hospital, or within the four walls of the provider's main building(WPS PB FAQ) www.northamericanhms.com 888.968.0076

14. When is Attestation Required? In essence, submissions and reviews will only be allowed when there is a difference in payment or beneficiary liability. When submitting an attestation, one of the questions that will be asked is, "what is the difference in payment between freestanding and provider-based status for this service?" If there is no difference, the attestation will immediately be closed with no recommendation made. (WPS PB FAQ) www.northamericanhms.com 888.968.0076

15. Big PB-Whoops A facility is only allowed to bill as provider-based if they meet the various financial and clinical integration and other criteria as stated in the regulations. Although the attestation and review process to document that you have met those criteria is voluntary, the requirement that you meet the criteria themselves is still effective. If later review determines that the criteria were not met, there is the possibility that additional money reimbursed due to billing as provider-based, rather than freestanding, will be recouped. (WPS PB FAQ) www.northamericanhms.com 888.968.0076

16. OCR Compliance Per Clinic www.northamericanhms.com 888.968.0076

17. Provider-based Criteria Licensure Clinical Services Financial Integration Public Awareness Obligations of hospital outpatient depts. Joint Ventures www.northamericanhms.com 888.968.0076

18. Licensure Provider-based clinics must meet state facility licensing requirements. Building, safety, fire codes, etc. www.northamericanhms.com 888.968.0076

19. Clinical Services The professional staff at the clinic must have clinical privileges at the parent entity. The main provider maintains the same monitoring as all other departments. The medical director of the facility maintains the same reporting relationship to the chief of staff as other departments. The same professional staff committees at the parent are responsible for medical activities at the clinic (QA, utilization review, integration of services, etc). www.northamericanhms.com 888.968.0076

20. Clinical Services Medical records for patients treated in the facility or organization are integrated into a unified retrieval system (or cross-reference) of the main provider. Inpatient and outpatient services of the facility or organization and the main provider are integrated, and patients treated at the facility or organization who require further care have full access to all services of the main provider and are referred where appropriate to the corresponding inpatient or outpatient department or service of the main provider. (CMS PM A-03-030) www.northamericanhms.com 888.968.0076

21. Financial Integration The financial operations of the facility or organization are fully integrated within the financial system of the main provider, as evidenced by shared income and expenses between the main provider and the facility or organization. (CMS PM A-03-030) www.northamericanhms.com 888.968.0076

22. Financial Integration The costs of a facility or organization that is a hospital department are reported in a cost center of the provider, costs of a provider-based facility or organization other than a hospital department are reported in the appropriate cost center or cost centers of the main provider, and the financial status of any provider-based facility or organization is incorporated and readily identified in the main provider's trial balance. (CMS PM A-03-030) www.northamericanhms.com 888.968.0076

23. Financial Integration Summarized The clinic is on the parent entity’s General Ledger. The clinic shares the same Tax ID with the parent. www.northamericanhms.com 888.968.0076

24. Public Awareness The provider-based clinic must be advertised as part of the parent entity. It’s affiliation with the parent entity must be clear to the public. www.northamericanhms.com 888.968.0076

25. Public Awareness - !!!! “As documentation, the provider may maintain examples that show that the facility is clearly identified as part of the main provider (i.e. a shared name, patient registration forms, letterhead, advertisements, signage, Web site). Advertisements that only show the facility to be part of or affiliated with the main provider’s network or healthcare system are not sufficient.” CMS Transmittal A-03-030 www.northamericanhms.com 888.968.0076

26. Obligations of Outpatient Departments Anti-dumping compliance Physician services use the correct place of service codes Physicians must comply with non-discrimination regulations All Medicare patients are treated as outpatient for billing (except RHCs) PPS payment windows apply www.northamericanhms.com 888.968.0076

27. Off-Site Location Provisions Operation under the ownership and control of the main provider Administration and supervision Location Management Contracts www.northamericanhms.com 888.968.0076

28. Operation, Supervision, and Control 100% ownership by parent entity Same governance as parent entity Same by-laws/organizing documents Parent entity has full responsibility and final authority Organizational structure and reporting requirements are the same as other departments of parent entity www.northamericanhms.com 888.968.0076

29. Location Requirements • Off-campus facilities must be within 35 miles of the parent entity with three exceptions: • Government entity or CAH with 11.75% disproportionate share • 75% patients reside in same zip code as 75% of hospital patients • RHCs attached to parent < 50 beds www.northamericanhms.com 888.968.0076

30. Management Contracts – Off Site locations Direct patient care staff are employees of the parent entity Administrative functions are integrated with parent entity Main provider has control over operations Contract is held directly by parent entity www.northamericanhms.com 888.968.0076

31. Hospital Considerations Clinical Services – includes all patient care services Does the CON include any other clinical services? How should these services be allocated for revenue and cost accounting purposes? What are the cost reporting ramifications for the hospital of integrating the Rural Health Clinic/Provider-based Clinic under the hospital www.northamericanhms.com 888.968.0076

32. Resources CMS Program Memorandum Change Request 2411. Transmittal A-03-030. April 18, 2003. Provider-based Clinic Reimbursement and Operational Issues. Steve Rader. Dan Larsen. LarsenAllen LLP. Joint AAHAM/HFMA Red Wing Institute. July 27, 2007. www.northamericanhms.com 888.968.0076

33. Links Office For Civil Rights – Hospitals http://www.hhs.gov/ocr/civilrights/resources/specialtopics/hospitalcommunication/index.html CMS PM - Change Request A-03-030 http://www.wpsmedicare.com/j5macparta/departments/audit_reimbursement/_files/pma-03-030iss041803.pdf www.northamericanhms.com 888.968.0076

34. Contact Information Charles A. James, Jr. North American Healthcare Management Services President and CEO 888.968.0076 cjamesjr@narhsinc.com www.northamericanhms.com www.northamericanhms.com 888.968.0076