Presented on Behalf of Nebraska Rural Health Association RHC Group By Janet Lytton, Director of Reimbursement Rural Health Development 308-647-6455 janet.lytton@rhdconsult.com April 16, 2016 1
Difference between Independent vs Provider Based Specialists in the RHC RHC, nonRHC services and locations Bundling of “incident to” services Exceptions for more than 1 visit per day paid 2
Understand how to bill: Mental Health (Behavioral Health) Billing Preventive Services Telehealth Services Hospice Services Medicare Secondary claims Claim form Completion and revenue codes used 3
Medicare Pt A = Hospital Service charges Most Patients receive these benefits without additional premium Medicare Pt B = Professional service charges Patients have choice of participating in Medicare Pt B benefits Additional premium for most of $104.60 (2016) RHC Services are professional services paid using Medicare Pt B eligibility, but paid through Medicare Pt A Payer Any DME supplies are only payable through DMERC Any Medicare Pt D Drugs are payable through the patient’s Pt D plan Medicare Pt C (Medicare Advantage) is outside the traditional Medicare coverages Plans can set equal to or greater benefits for patients 4
Patient Deductible = $166 per year IRHC Rate = $81.32/visit PBRHC PPS Hospital Rate = $81.32/visit PBRHC <50 bed hospitals = No limit 5
An RHC is a certification from CMS that allows physician practices to qualify for cost-based reimbursement from Medicare and Medicaid 4,100 RHCs across the country out of 230,187 physician practices (1.7%) Who are the RHCs in your State? http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/ rhclistbyprovidername.pdf 6
CMS has an “RHC Fact Sheet” http://www.cms.gov/Outrea ch-and-Education/Medicare- Learning-Network- MLN/MLNProducts/downlo ads/ RuralHlthClinfctsht.pdf 6 pages of information 7
• Independent Rural Health Clinic • Owned by any person that State allows • I.e. Physicians, NPs, PAs, Hospitals, or anyone allowed • Individual practitioner(s) • Can be sole proprietor, partnership, corp. or LLC • Completes the IRHC cost report each year • Provider Based Rural Health Clinic • Owned by a Hospital, Skilled Nursing Facility or a HHA • Treated as a department of the parent facility • Generally within a 35 mile radius of the parent facility • Integrated financials • Access to medical records between departments • Cost report completed as part of the “parent” cost report 8
State Operations Manual — Conditions for Certification Compliance with Federal, State, and Local Laws Location of Clinic Physical Plant and Environment Organizational Structure Staffing and Staff Responsibilities Provision of Services Patient Health Records Program Evaluation Appendix G – Guidance to Surveyors: Rural Health Clinics (RHCs) – (Rev. 1, 05-21-04) 9
Survey for Certification as an RHC Initial Survey Periodic Surveys Complaint Surveys Surveys after Initial Typically every 5 years but may be longer Not necessarily after a Change of Ownership but maybe Deficiency Statement Plan of Correction 10
• Must be in a “rural” area • Population of 50,000 or less and in a • nonmetropolitan area (last census determines) • Would lose RHC designation if Clinic falls out of “rural” designation • Must be in a “shortage” area • Currently do not lose RHC status if area is not in a current shortage area • Keep up-to-date knowing if your area is designated • If moving clinic, assure site is still in a shortage area 11
• RHC must be located in a healthcare shortage area • Health Professional Shortage Area (HPSA) • Medically Underserved Area (MUA) • Medically Underserved Population does not meet the shortage area designations (MUP) • Governor’s list of Healthcare Shortage Areas • Check website: • http://www.hrsa.gov/shortage/find.html • Search to find your area as either a HPSA or MUA • Check the State website for governor’s list of shortage areas 12
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Scope of Practice Follows State’s Medical Practice Act Have written delineation of duties for PAs and NPs Providing RHC Services Medical Services that are normally performed in a physician clinic RHC must be “primarily engaged” in RHC services at least 51% of the total operating schedule Patient Care Policies All policies signed off by providers and Governing body Description of services — direct and indirect services 14
Patient Care Policies (continued) Guidelines for medical management of patients Regimens to follow and conditions that are treated Describe medical procedures allowed by NP, PA or CNM Describe medical conditions that require consultation/referral Drugs and Biologicals Policies on storage of drug — humidity, temp, light, etc Policies on outdated, deteriorated or adulterated drugs All drugs locked; all narcotics double locked & counted Have current drug references and antidote information Prescribe and dispense in compliance with State law 15
Review of Policies Patient Care Policies reviewed by professional personnel at least annually and documented Keep all prior outdated policies on file Direct Services Required Services Diagnostic Examination 6 Basic Laboratory Services (CLIA Waived Certificate) Emergency treatments 16
Records System Written Policies on Maintenance of Records Responsibility of Designated Professional Record on Each Person Receiving Healthcare Service Records kept onsite Review of records Required Protection of Records All Must Be Kept Secure Release of Records Policies Required Services Retention of Records Federal Law States at least 6 years from last entry or longer if State Requires; or 6 years after age of majority 17
Evaluation of Clinic’s Total Operation Must be Completed Annually by the “Advisory Council” Must include one “third party person” on Council Not All Have to be Completed at the Same Time by the Same Staff Written Report of Annual Evaluation Required Annual Review Must Include Review of Services Provided to Include Numbers of Patient Services and What Services Provided Review of Records to include Active and Closed Charts Review of All Policies and Procedures and changes made 18
Medicare Benefit Policy Manual Ch 13 – RHC and FQHC Services Rev 220, 1/15/16 https://www.cms.gov/Regulations-and-Guidance/ Guidance/Manuals/Downloads/bp102c13.pdf 19
Independent RHC Billing RHC claims sent to the Medicare payer assigned in the past or if new RHC, will be with your local MAC IRHCs are capped at $81.32 per visit 2016, (1.1% increase over 2015, $80.44) All professional services in Clinic, SNF, NH, AL, Home, at scene of an accident Completes a cost report each year, CMS 222-92 nonRHC services sent to Medicare Pt B MAC IP, OP, ER, OBS Bed, TCs of screening and diagnostic tests, i.e. EKG tracing, x-ray TC 20
Provider Based Billing RHC claims sent to Medicare payer of “Parent” facility If PBRHC part of a <50 bed hospital, no cap on rate If PBRHC part of a >50 bed hospital, capped at IRHC rate Many times these will be set up as IRHCs PBRHC a section of the Hospital cost report nonRHC service claims sent through hospital OP # TCs, i.e. EKG Tracing, X-ray TC; labs nonRHC service claims sent to Medicare Pt B IP, OP, ER, OBS Bed Exception for CAHs Method II as OP, ER, OBS Bed professional services submitted by Hospital on their claim — 15% additional reimbursemen t 21
Physicians — M.D. or D.O . Family Med; Internist; Pediatric; OB/GYN; Gerontology Physician Assistants Nurse Practitioners, Certified Nurse Midwife Psychologists (phD) & LCSW (Masters level w 2 yrs) Must be licensed in the State providing the services Specialists Must be < 50% of total visits (includes mental health srvs) IF specialist is a provider of the RHC, then RHC visits Specialist is paid through the RHC IF visiting specialist “periodically” in the RHC and: Not paid through the RHC Billing is separate from the RHC billing Typically pays a rental/lease fee for space/supplies used 22
RHC Services (Sec. 50.1 of RHC Benefit Manual) Physician Services & services & supplies incident to NP, PA, CNM Services & services & supplies incident to CP and CSW Services & services & supplies incident to Visiting Nurse services in HHA shortage area Medicare allowed Preventive Services Influenza, Pneumococcal & Hepatitis B Vaccinations Hepatitis C screenings IPPE AWV All Medicare-covered preventive services All Services paid based on RHC AIR (all inclusive rate) 23
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