To Be or Not to Be.. a Rural Health Clinic

To Be or Not to Be.. a Rural Health Clinic Virginia Rural Healthcare Association Annual Conference October 19, 2016

Today s Session 1. Rural Health Clinics (RHC) 2. Federally Qualified Health Centers (FQHC) 3. Requirements for RHC and FQHC 4. RHC Billing 5. RHC Regulatory Requirements 6. Panel Discussion 7. Group Q&A

A Rural Health Clinic is.. RHC = Rural Health Clinic It is a cost based reimbursed federal program for Medicare and Medicaid patients in a primary care office Provide healthcare services for insured, uninsured, and underinsured

Rural Health Clinic The Rural Health Clinic Services Act of 1977 (Public Law 95-210) was enacted to address an inadequate supply of physicians serving Medicare patients in rural areas and to increase the use of non-physician practitioners such as nurse practitioners (NPs) and physician assistants (PAs) in rural areas. There are 4,099 RHCs nationwide furnishing primary care and preventive health services in rural and underserved areas. Source: CMS.gov

Why RHC? Higher reimbursement from Medicare and Medicaid Higher reimbursement for influenza and pneumococcal vaccines No reduced payment for NP & PA services Payment of Medicare bad debt 2016-65%

RHC Requirements Be located in a non-urbanized area as defined by the United States (U.S.) Census Bureau and Be located in a Medically Underserved area (MUA), Health Professional Shortage Area (HPSA) or Governordesignated and Secretary-Certified shortage area: (designated within the last 4 years by HRSA) Provide outpatient primary care services Use the services of a PA, NP, or CNM at least 50% of clinic hours

RHCs May Be Either Independent (Free Standing) Owned and operated by a physician, NP, PA, or CNM Provider-based Owned and operated by a hospital, skilled nursing home or home health agency

Reimbursement Differences Independent Medicare payment $81.32 Use form 222 Ownership physician, NP, PA Provider-based No cap on Medicare payment when less than 50 available beds Must meet providerbased criteria 855A Ownership - hospital

What is a Provider-based RHC? It is not a provider-based clinic No EMTALA obligations No split billing requirements No 35 mile restrictions if less than 50 beds It is a subpart of the hospital The RHC has it s own NPI and PTAN number

Federally Qualified Health Center (FQHC) Federally qualified health centers (FQHCs) include all organizations receiving grants under Section 330 of the Public Health Service Act (PHS). FQHCs qualify for enhanced reimbursement from Medicare and Medicaid, as well as other benefits.

FQHCs Provide care for people in rural and urban areas labeled as medically underserved areas or medically underserved populations(mua & MUP) Board of Directors required May receive funding for start up Must provide services to all community residents More comprehensive services: lab, diagnostic, behavioral and oral, after-hours, case management, pharmaceutical, transportation, interpretative services Under Federal objective review

FQHC Must: Serve an underserved area or population Offer a sliding fee scale Provide comprehensive services Have an ongoing quality assurance program

FQHC Certification Requirements To be certified as an FQHC, an entity must meet one of the following requirements: Is receiving a grant under Section 330 of the Public Health Service (PHS) Act or is receiving funding from such a grant and meets other requirements; Is not receiving a grant under Section 330 of the PHS Act but is determined by the Secretary of the Department of Health & Human Services (HHS) to meet the requirements for receiving such a grant (qualifies as a FQHC look-alike ) based on the recommendation of the Health Resources and Services Administration; Was treated by the Secretary of HHS for purposes of Medicare Part B as a comprehensive Federally-funded health center as of January 1, 1990; or Is operating as an outpatient health program or facility of a tribe or tribal organization under the Indian Self-Determination Act or as an urban Indian organization receiving funds under Title V of the Indian Health Care Improvement Act as of October 1991

Differences Between RHC and FQHC Location urbanized vs. non urbanized Range of services Scope of benefits How federal government administers both programs

Overview of RHC and FQHC Programs Comparison of Basic Eligibility Criteria Criteria Rural Health Clinic Federally Qualified Health Center Location Non-urbanized Area N/A Shortage Area Corporate Structure MUA,HPSA or Governor Designated Shortage Area Unincorporated, public, nonprofit or for profit MUA or MUP Board of Directors N/A Required Tax-exempt nonprofit or public Clinical Staffing NP or PA required at least 50% of the time the clinic is open No specific requirements HRSA Comparison of RHC and FQHC - 2006

Management and Finance Evaluation Comparison of Management Criteria Criteria Rural Health Clinic Federally Qualified Health Center Compliance with Civil Rights Act Written Policies and Procedures Required annual evaluation of clinic operations Required Required Required annual evaluation of clinic utilization Assurance required Required Sliding Fee Scale Not Required Required Initial Application Application forms and on-site survey Application narrative and on-site survey (on-site survey is not mandatory for FQHCs or look-alikes at the time of application Recertification On-site survey State of compliance with program requirements Management and Control Systems Must demonstrate ability to manage costbased reimbursed Must provide written description of systems Independent Financial Audit Not Required Required Governance No specific requirements User-majority board of directors required HRSA Comparison of RHC and FQHC - 2006

Comparison of Required Scope of Services Criteria Rural Health Clinic Federally Qualified Health Center Primary Health Care Services Required Required Primary Care for all life-cycle ages Not Required Required on-site or under arrangement Basic Lab Six specified tests required on-site, others required on-site or under arrangement Required on-site or under arrangement Emergency Care First response capabilities required Required on-site or under arrangement Radiological Services Required onsite or under arrangement Required on-site or under arrangement Pharmacy Not Required Required on-site or under arrangement Preventative Health Not Required Required on-site or under arrangement Preventative Dental Not Required Required on-site or under arrangement Transportation Not Required Required on-site or under arrangement Case Management Not Required Required on-site or under arrangement Dental Screening for Children Not Required Required on-site or under arrangement After Hours Care Not Required Required Hospital/Specialty Care Required by clinic staff or under arrangement Required by clinic staff or under arrangement HRSA Comparison of RHC and FQHC - 2006

RHC - Conditions for Participation Compliance with Federal, State and Local Laws Location of Clinic Physical Plant and Environment Organizational Structure Provision of Services Patient Health Records Program Evaluation

RHC Organizational Structure The clinic is under the direction of a Medical Director Written material covering organization policies, including lines of authority and responsibilities Written policies should consist of both administrative and patient care policies Disclosure of names and addresses: The clinic discloses names and addresses of the owner, person responsible for directing the clinic s operation and physician responsible for medical direction.

Staffing RHC must employ at least one NP or PA (RHCs may contract with NPs, PAs, CNMs, CPs, and CSWs when at least one NP or PA is employed by the RHC) The staff is sufficient to provide the services essential to the operation of the clinic NP, PA, or CNM must be present 50% of clinic hours; and Medical Director must be on site for sufficient periods of time dependent on needs of facility and patients

Staff Responsibilities The Medical Director in conjunction with the NP or PA participates in the developing, executing and periodically reviewing the clinic s written policies and procedures as well as periodically, reviews the clinic s patient records.

Provision of Services Each RHC must be capable of providing out-patient primary care services RHC services include visit to the clinic, patients residence, assisted living facility, Medicare-covered Part A Skilled Nursing Facility Have arrangements with one or more hospitals to furnish medically necessary services that are not available at the RHC Have available drugs and biologicals necessary for the treatment of emergencies

Laboratory Services Provides basic laboratory services: Chemical examinations of urine Hemoglobin or Hematocrit Blood sugar Examination of stool specimens for occult blood Pregnancy test Primary culturing for transmittal

Non-Medical Emergencies The clinic assures the safety of patients in case of non-medical emergencies by: 1. Training staff in handling emergencies 2. Placing exit signs in appropriate locations 3. Taking other appropriate measures such as: bomb, fire and severe weather drills

Annual Program Evaluation The clinic carries out, or arranges for, an annual evaluation of its total program to include: The utilization of clinic services including number of patients served Random sample of both active and closed records (10 open and 5 closed) Review the clinic s health care policies for needed changes The clinic staff considers the findings and takes corrective action if necessary

Recertification Periodic on-site survey (at least once every 6 years) Unannounced Review of RHC Conditions of Participation Deficiencies: None, Standard, Condition Follow-up: Onsite or by mail Plan of Correction: Deficiencies corrected

Survey - Clinic Tour Drug samples Storage of medications include scheduled drugs no expired drugs Autoclave Exit signs Posted fire regulations Medical record review Conversation with staff Policy review

Survey - Clinic Tour - cont. Handicapped access Premises clean and orderly Infection control and equipment processing Preventive maintenance Fire safety and disaster drills

When to Notify State Agency Change of ownership Move to a new location Loss of NP or PA Staffing waiver request Change in Medical Director New NP or PA Termination of RHC New clinic to be certified

RHC Billing Cost based reimbursement Payments are based on an all-inclusive payment methodology and subject to maximum payment per visit an annual reconciliation referred to as an encounter rate Part B Deductible and coinsurance for Medicare patients is still 20 percent of the reasonable and customary charges except for certain services i.e., OP mental health treatment Medicare pays 100% percent of costs for preventative services

Annual Reconciliation Cost Report The RHC submits a report to the Medicare Administrative Contractor (MAC) that includes actual allowable costs and actual visits for RHC services for the reporting period and any other information that may be required The MAC divides allowable costs by the number of actual visits to determine a final rate for the period The MAC determines the total payment due and the amount necessary to reconcile payments made during the period with the total payment due Both the interim and final payment rate are reviewed for productivity, reasonableness, and payment limitations

Annual Reconciliation - Cost Reports Medicare Cost report due to Medicare MAC 5 months after fiscal year end. Ex: If your year end is 12/31, then it is due no later than 5/31

Cost Reports cont. Medicaid A projected cost report is submitted to the Medicaid Agency at time of enrollment as RHC to establish the all-inclusive encounter rate. However, if scope of services changes, additional information will need to be submitted for consideration of increase of rate.

How do RHC Costs Compare to RHC Payments? Finerfrock, W.: Capstone VRHA, 2016

RHC Cost Per Visit Comparison Finerfrock, W.: Capstone VRHA, 2016

RHC Cost Per Visit Comparison Finerfrock, W.: Capstone VRHA, 2016

How to Certify as an RHC? 1. Determine if site is eligible 2. Evaluate the financial feasibility of RHC status based on estimated data on payer mix 3. File an RHC application and a CMS provider enrollment form 4. RHC certification inspection 5. File a projected cost report to have Medicare rate determined

Virginia Rural Health Clinic Coalition Initiated in March 2016 Fourteen Rural Health Clinics Provides training, education, networking, regulation updates, RHC advocacy and more

Panel Discussion Travis Clark, President - Page Memorial Hospital and Shenandoah Memorial Hospital; VP of Operations Valley Health South Region Phillip Graybeal VP of Finance, Valley Health South Region Denise Dale Valley Physician Enterprise South Region Manager of Clinic Operations

References/Resources U.S. Department of Health and Human Services (2006): Comparison of the Rural Health Clinic and Federally Qualified Health Center Programs. Web site: http://hrsa.gov/ruralhealth/policy/confcall/comparisonguide.pdf U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services (2016): Rural Health Clinic Fact Sheet. Web site: https://www.cms.gov/outreach-and-education/medicare-learning-network- MLN/MLNProducts/downloads/RuralHlthClinfctsht.pdf National Association of Rural Health Clinic. (2016). Web site: http://narhc.org/discussions-2/legislate-updates/ National Rural Health Association, website 2016; http://www.ruralhealthweb.org/ State Operations Manual Appendix G Guidance to Surveyors -Rural Health Clinics, CMS. (2015). Web site: https://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/downloads/som107ap_g_rhc.pdf Virginia Rural Health Association (2016). Web site: http://vrha.org/ Medicare Benefit Policy Manual, Chapter 13 Rural Health Clinic and Federally Qualified Health Center Services (2016). Web site: https://www.cms.gov/regulationsand-guidance/guidance/manuals/downloads/bp102c13.pdf GPO U.S. Government Publishing Office, ecfr (2016). Web site: http://www.ecfr.gov/cgibin/retrieveecfr?gp=&sid=bd5ea765b228085fc1b9f5a7366f85a0&n=42y2.0.1.2.5.15&r=su BPART&ty=HTML