RURAL HEALTH CLINIC BASICS GLEN BEUSSINK NATIONAL ASSOCIATION OF RURAL HEALTH CLINIC INDIANAPOLIS FALL INSTITUTE 2017

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1 RURAL HEALTH CLINIC BASICS GLEN BEUSSINK NATIONAL ASSOCIATION OF RURAL HEALTH CLINIC INDIANAPOLIS FALL INSTITUTE 2017

2 AGENDA Overview RHC Rules Brainstorming Objectives & Questions and Answers Best Practices Summarize

3 WHAT YOU NEED TO KNOW CMS , State Operations Manual (Proposed up date) RHC Benefits Manual Chapter CFR 405 Regulations 42 CFR (Certification) RHC Fact Sheet Type/Rural-Health-Clinics-Center.html

4 RHC CERTIFICATION OVERVIEW Where can you locate a RHC? Health Professional Shortage Area (HPSA) (within 4 year) Geographic Low-Income, Population Governors Designated Rural Area, Urban Cluster is a Rural Area

5 RHC SERVICES Must be 51 % Primary Care Thus you can offer other services such as Specialty or Mental Health

6 RHC SERVICES Physician Services Services/Supplies incident to the provider 6 CLIA waived tests (billed to Part B) Drugs furnished incident to the office visit Routine testing normally done in a physician s office (TC billed to Part B) Have arrangements to transfer patients Common Emergency drugs and biologicals Annual Program Evaluation Meet Federal and State Laws

7 RHC CERTIFICATION OVERVIEW Staffing Nurse Practitioner Physician Assistant Certified Nurse Mid-Wife (must employ one) 50% Specialist and other providers, Clinical Psychologist, Licensed Clinical Social Worker (mental health)

8 RHC CERTIFICATION OVERVIEW Laboratory (CLIA Waived) Urine Hemoglobin or Hematocrit Blood Sugar Stool, occult blood Pregnancy test Primary Culturing ability

9 RHC ENCOUNTER/VISIT Medically Necessary Review labs or order/renew medications, not a visit Face to Face Welcome to Medicare/Annual Wellness (no copay) Typically one visit per day, except for illness, mental health Initial Preventive Physical Exam (IPPE)

10 OVERVIEW, CERTIFICATION SURVEY Certification Survey What to expect Facility Review Chart Review Policy Manual Review Human Resources Review, License, Office of Inspector General, Credentials, etc. General Medical Practices

11 YOUR POLICY MANUAL Policy Manual Review, Structure Description of Services Description of the Chart Health Information Patient Portability Act, Office of Civil Rights General Best Practices Train, Train, Train

12 MEDICAL RECORDS Charts are generally no different that any Fee For Service practice 42 CFR Record Section Consent to Treat & Surgery Consent Health Insurance Portability Accountability Act (HIPAA) Medicare Secondary State Laws

13 REIMBURSEMENT & COST REPORTS RHC are paid on an All Inclusive Rate (AIR) Current AIR, Independent Clinic rate is $82.30 Provider Based, less than 50 beds on the Medicare Cost Report has no cap rate Paid at 80 % of your clinic rate, PLUS 20 % of CHARGES A RHC Cost Report is required each year Quarterly Credit Balance Reports, required

14 INDEPENDENT - EXAMPLE PAYMENT RATE Your rate $82.30 (AIR Cap 2017) You will receive 80% or $65.84 (based on cost) Your Charge for a is $ or about 2 times Medicare Thus the payment from the patient, secondary or Medicaid (most states) will be $27.20 Total payments $93.04 WPS Fee for Service, Rate for MO is about $69.00 Mid Levels are reduced by 15% for Fee For Service, thus they would only receive $58.65 instead of the average rate of $69.00

15 PROVIDER BASED - EXAMPLE PAYMENT RATE Your rate is $ (example) You will receive 80% or $ Your Charge for a is $ or about 2 times Medicare Thus the payment from the patient, secondary or Medicaid (most states) will be $27.20 Total payments $ or slightly less than actual cost

16 RHC CLAIMS - ONLY THE BASICS Claims are paid on the CMS 1450, commonly known as the UB04 or institutional claim format, with Revenue Codes and CPT codes Physician Service payments come from the Part B using the process above Because we must use a cost setting process by the Medicare Cost Report, we file claims to an institutional Medicare Administrator Contractor (Cahaba is moving to Palmetto, in February, all current legacy providers will also move.)

17 ANNUAL EVALUATION THE BASICS 42.CFR Active and Closed Charts Policy Manual Review Utilization of Services Established Policies are being followed Any Changes Necessary Take Action

18 PRODUCTIVITY REQUIREMENTS Encounter/Visits are based on Full Time Equivalent FTE is based on time with patients, less vacation, off-site work, education, meeting etc. Physicians 4,200 Mid-Levels 2,100 Use a combination method (really old rules, 1976)

19 RHC VISITS WHERE - THE BASICS At the Clinic (521) Place of Residence, Home Nursing Home Assisted Living Swing Bed in the Hospital Must be Medically Necessary

20 PROVIDER BASED - THE BASICS CMS A An entity Not all rules apply, such as the mileage rules

21 ACCREDITATION & STATE RHC SURVEY State Dept. of Health Survey and Certification Branches Many are Laboratory or Hospital Surveyor Not consistent Varied timing, 5-7years Not fair to all

22 ACCREDITATION & STATE RHC SURVEY AAAASF - American Association for Accreditation of Ambulatory Surgery Facilities TCT - The Compliance Team AO - Accreditation Organization Typically a State Survey is ½ day Accreditation is typically most of the day, you will meet a higher standards for each Accreditation is a selling point of the organization

23 CONTACT INFORMATION Glen Beussink Director of Clinic Development Midwest Health Care, Inc