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Rural Health Clinic 101

Rural Health Clinic 101. Charles A. James, Jr. President and CEO North American Healthcare Management Services. Presentation Overview. What is an RHC? Independent vs. Provider-Based RHCs RHC Location Requirements RHC Billing and Reimbursement Basics

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Rural Health Clinic 101

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  1. Rural Health Clinic 101 Charles A. James, Jr. President and CEO North American Healthcare Management Services www.northamericanhms.com 888.968.0076

  2. Presentation Overview • What is an RHC? • Independent vs. Provider-Based RHCs • RHC Location Requirements • RHC Billing and Reimbursement Basics • RHC Applications and Inspection Process • Basic RHC Requirements • RHC Manual • RHC Resources www.northamericanhms.com 888.968.0076

  3. What is an RHC? Rural Health Clinics were established by the Rural Health Clinic Service Act of 1977 to address an inadequate supply of physicians serving Medicare beneficiaries in underserved rural areas, and to increase the utilization of nurse practitioners (NP) and physician assistants (PA) in these areas. RHCs have been eligible to participate in the Medicare program since March 1, 1978, and are paid an all-inclusive rate per visit for qualified primary and preventive health services. (Medicare Benefit Policy Manual. Chapter 13. Section 10.1.) www.northamericanhms.com 888.968.0076

  4. What is an RHC? A Rural Health Clinic (RHC) is a clinic certified to receive special Medicare and Medicaid reimbursement.  The purpose of the RHC program is improving access to primary care in underserved rural areas.  The clinic must be staffed at least 50% of the time with a midlevel practitioner. (Rural Assistance Center FAQ) www.northamericanhms.com 888.968.0076

  5. The Rules - 42 CFR 491 This is the Code of Federal Regulations (CFR) which stipulates rural health clinics’ conditions for certification. http://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/RHC_FQHC.html www.northamericanhms.com 888.968.0076

  6. 42 CFR 491 • Compliance with Federal, State, and Local laws • Location of Clinic • Physical Plant and Environment • Organizational Structure • Staffing and Staff Responsibilities • Provision of Services • Policy and Procedure Manual • Medical Records • Annual Evaluation (vs. Quality Assurance) www.northamericanhms.com 888.968.0076

  7. Compliance with Federal, State, Local Laws The clinic must be in compliance with federal RHC regulations and Medicare law. (J3) The clinic and staff are licensed pursuant to applicable State and local law. (J3 and J4) The clinic building meets applicable building and fire codes. (J5) www.northamericanhms.com 888.968.0076

  8. Who’s in charge – the State or the Feds? Short Answer – Both The State Department of Health typically perform inspections. They are an agent of CMS for the purpose of an RHC survey. CMS interprets and enforces the federal RHC regulations. CMS approves or denies the state’s recommendations. www.northamericanhms.com 888.968.0076

  9. The RHC Encounter Rate “In general, the all-inclusive rate (AIR) for an RHC or FQHC is calculated by the MAC/FI by dividing total allowable costs by the total number of visits for all patients. Productivity, payment limits, and other factors are also considered in the calculation.” (Medicare Benefit Policy Manual. Chapter 13. Section 70.) www.northamericanhms.com 888.968.0076

  10. RHC Reimbursement Currently, independent RHCs are capped at $79.80 for 2014. An average provider-based RHC encounter rate is between $140.00 – 167.00. www.northamericanhms.com 888.968.0076

  11. RHC Claims - Medicare Part A Rural Health Clinic claims are administered by Medicare Part A. It is a Part B (Physician Service) benefit, using the structure of Medicare Part A. This is why we deal with UB04, Cost Reports, Revenue Codes, etc. www.northamericanhms.com 888.968.0076

  12. Medicare Part B (FFS) In the RHC world, the term ‘Medicare Part B’ typically indicates those claims which will continue to be paid ‘fee-for-service’ and billed on a CMS-1500. Non-RHC claims fall in this category. www.northamericanhms.com 888.968.0076

  13. Medicare Payments “In general, Medicare pays 80 percent of the RHC or FQHC’s all-inclusive rate, subject to a per-visit payment limit. The beneficiary in an RHC must pay the deductible and coinsurance amount.” (Medicare Benefit Policy Manual. Chapter 13. Section 80.) www.northamericanhms.com 888.968.0076

  14. Medicare Fees (Patient Charges) “RHCs and FQHCs must charge Medicare beneficiaries the same rate that non-Medicare beneficiaries are charged.” (Medicare Benefit Policy Manual. Chapter 13. Section 80.) www.northamericanhms.com 888.968.0076

  15. RHC Productivity Standard 1 FTE Physician – 4,200 Visits 1 FTE NP or PA – 2,100 Visits If the RHC or FQHC has furnished fewer than expected visits based on the productivity standards, the MAC/FI substitutes the expected number of visits for the denominator and use that instead of the actual number of visits. (Medicare Benefit Policy Manual. Chapter 13. Section 70.4.) www.northamericanhms.com 888.968.0076

  16. Medicare Law Rural Health Clinics are not special – we are all subject Medicare law, regulations, and policies. Some Medicare provisions do not apply to us. www.northamericanhms.com 888.968.0076

  17. Medicare Documentation Consent to treat Authorization to Bill HIPAA Privacy notification Medicare Secondary Payer Questions Asked • Pub 100-5 Chapter 3, section 20 ABN issued if applicable • when service does not meet medical necessity • Statutorily excluded Medicare services do not require an ABN, I.e. physical, can give NEMB Surgical Consent www.northamericanhms.com 888.968.0076

  18. State Law and Medicaid State medical practice laws, collaborative requirements, and Medicaid programs vary widely. Always check with state agencies and Medicaid offices before making any assumptions. www.northamericanhms.com 888.968.0076

  19. Independent RHCs Independent RHCs are generally private physician offices or hospital clinics whose parent is > 50 beds. RHC encounters are paid using the current RHC cap. Independent RHCs must file an annual cost report, which is due 5 months after the end of each fiscal year. Failure to file timely cost reports can result in full refunds of RHC payments. www.northamericanhms.com 888.968.0076

  20. Provider-Based RHCs Provider-based RHCs (PBRHC) are those owned by, and fully integrated with, a parent entity such as a hospital, nursing facility, or home health agency. PBRHCs owned by a hospital with 50 beds or less qualify for an un-capped RHC rate. Claims are billed to the MAC which services the parent entity. PBRHCs whose parent entity is greater than 50 beds have the same cap as independents. PBRHCs rate is set under the parent entity’s cost report. www.northamericanhms.com 888.968.0076

  21. 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

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

  23. Provider-based Clinic Definition The PB-RHC IS an outpatient department of the hospital. In all manner – the RHC will be administered, operated, and financially integrated with the parent entity. www.northamericanhms.com 888.968.0076

  24. Provider-based Attestation The purpose of the attestation is to demonstrate integration with the parent entity. Provider-based attestations are required if PB status provides a difference in payment. Provider-based attestations are required for off-site clinics. www.northamericanhms.com 888.968.0076

  25. RHC Location Requirements RHCs must be located in one of the following: Geographic-based Health Professional Shortage Area (HPSA) Population-based HPSA Medically Underserved Areas (MUAs) Governor Designated and Secretary certified area The shortage area designation must have been updated within the past four years. www.northamericanhms.com 888.968.0076

  26. RHC Location Requirements The clinic must also be located in a non-urban area according to the U.S. Census Bureau. RAC ‘Am I Rural’ lookup tool: http://maps.rupri.org/circ/racrural/amirural.asp www.northamericanhms.com 888.968.0076

  27. RHC Inspections – Tier IV Now that AAAASF has deemed status, RHCs are moved to Tier IV. RHCs are now Tier IV entities which places them on a very low priority for survey by the state. Most states are requiring new RHC applicants to pursue private accreditation. www.northamericanhms.com 888.968.0076

  28. Medicare 855A Medicare will take at least 60 days to approve the 855A application. The clinic will receive an approval letter from CMS. Once the 855 is approved, the clinic can request the inspection. www.northamericanhms.com 888.968.0076

  29. RHC Physician Staffing Requirements The clinic must have a designated medical director. A physician must be present in the clinic once every two weeks. The physician/medical director must see at least one patient and provide medical direction, consultation, and oversight. www.northamericanhms.com 888.968.0076

  30. RHC Mid-Level Provider (MLP) Requirements A nurse practitioner, physician assistant, or certified nurse mid-wife must be employed by the RHC. The MLP must be available for patient at least 50% of posted patient hours. www.northamericanhms.com 888.968.0076

  31. RHC Approved Providers • Physicians – M.D. or D.O. • Mid-level providers – N.P., P.A., or C.N.M. • Mental Health Providers: • Clinical Psychologist – Ph.D. • Licensed Clinical Social Worker • (NO L.P.C. or C.P.C!) www.northamericanhms.com 888.968.0076

  32. Rural Health Services • Physicians' services, as described in section 100; Services and supplies incident to a physician’s services, as described in section 110; Services of NPs, PAs, and CNMs, as described in section 120; Services and supplies incident to the services of NPs, PAs, and CNMs, as described in section 130; (Medicare Benefit Policy Manual Chapter 13) www.northamericanhms.com 888.968.0076

  33. RHC Encounters are not: Visits for the sole purpose of obtaining or renewing a prescription, in which the need was previously determined are not covered services. Reviewing lab results. Administration of an injection. Time used in completion of claim forms. Care plan oversight (telephone) is not allowed by either Part A or Part B for RHC providers. www.northamericanhms.com 888.968.0076

  34. Physician Services The term “physician” includes a doctor of medicine, osteopathy, dental surgery, dental medicine, podiatry, optometry, or chiropractic who is licensed and practicing within the licensee’s scope of practice, and meets other requirements as specified. (Medicare Benefit Policy Manual. Chapter 13. Section 100.) www.northamericanhms.com 888.968.0076

  35. Qualified RHC Providers An RHC encounter can be billed for the following providers: Physicians (MD, or DO) Nurse Practitioners, Physician Assistants, and Certified Nurse Midwives Clinical Psychologists (PhD) Clinical Social Workers (CSW or LCSW) www.northamericanhms.com 888.968.0076

  36. Provision of Incident-to Services Incident to services and supplies can be furnished by auxiliary personnel. More than one incident to service or supply can be provided as a result of a single physician visit. Incident to services and supplies must be provided by someone who has an employment agreement or a direct contract with the RHC or FQHC to provide services www.northamericanhms.com 888.968.0076

  37. Provision of Incident-to Services Services and supplies furnished incident to physician’s services are limited to situations in which there is direct physician supervision of the person performing the service. Direct supervision does not mean that the physician must be present in the same room…the physician must be in the RHC or FQHC and immediately available. (Medicare Benefit Policy Manual. Chapter 13. Section 110.1) www.northamericanhms.com 888.968.0076

  38. Incident-to Services Defined Commonly rendered without charge or included in the RHC or FQHC bill; Commonly furnished in a physician office or clinic; Furnished under the physician’s direct supervision; and Furnished by a member of the RHC or FQHC staff. Drugs and biologicals that are not usually self-administered, and Medicare-covered preventive injectable drugs (e.g., influenza, pneumococcal); Bandages, gauze, oxygen, and other supplies; or Assistance by auxiliary personnel such as a nurse, medical assistant, or anyone acting under the supervision of the physician. www.northamericanhms.com 888.968.0076

  39. Incident-to Services Defined Incident-to services are considered covered and paid under the RHC. They must be bundled with the RHC encounter. They are not separately billable or payable. Services that do not occur on the same date as the encounter can be bundled if they occur 30 days before or after. The effect on payment is an increase in the charge, and therefore in the co-insurance. The cost for these services are included in the cost report, but are not separately payable on claims. www.northamericanhms.com 888.968.0076

  40. Examples of incident-to services Injections Suture Removal Dressing Changes Prescription Services Blood Pressure Monitoring www.northamericanhms.com 888.968.0076

  41. How to Bundle Services Example: An office visit for $105.00 and an injection for $75.00 is provided by the physician, NP, PA, or CNM. One line item for $180.00 will be submitted to Medicare. The patient (or secondary) will be responsible for $36.00 (20% co-insurance). www.northamericanhms.com 888.968.0076

  42. How RHC Medicare Services are Billed: * Costs related to services reimbursed under Part B are carved out on the RHC cost report so that the encounter rate is not overstated (double-dipping).

  43. Preventive Services - Billing The IPPE and AWV are Medicare covered preventive services. These are RHC encounters. They should be billed with the HCPCS code on a UB04. There is no cost sharing (i.e. no patient deductibles or co-ins.) for IPPEs and AWVs. www.northamericanhms.com 888.968.0076

  44. Full RHC Regulation This is the Code of Federal Regulations (CFR) which stipulates rural health clinics’ conditions for certification. Cut and Paste this into your browser: http://www.narhc.org/resources/rhc_rules_and_guidelines.php www.northamericanhms.com 888.968.0076

  45. Rural Health Resources National Association of RHCs (NARHC) www.narhc.org AAAASF - rhcaccreditation.org Rural Assistance Center http://www.raconline.org/topics/clinics/rhc.php www.northamericanhms.com 888.968.0076

  46. CMS and Medicare Resources CMS Rural Health Center – www.cms.gov/center/rural.asp Online Manuals - www.cms.gov/Manuals/IOM/list.asp?listpage=1 Cahaba – www.cahabagba.com WPS – Provider-Based Status FAQ http://wpsmedicare.com/j5macparta/departments/audit_reimbursement/prbattestationsfaqs.shtml www.northamericanhms.com 888.968.0076

  47. More CMS Resources Medicare Claims Processing Manual – UB04 Completion www.cms.gov/manuals/downloads/clm104c25.pdf Medicare Claims Processing Manual – Chapter 9 RHC/FQHC Coverage Issues www.cms.gov/manuals/downloads/clm104c09.pdf MedLearn Catalog www.cms.gov/MLNProducts/downloads/MLNCatalog.pdf www.northamericanhms.com 888.968.0076

  48. 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

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