Nebraska Rural Health Association RHC Group By Janet Lytton, - PowerPoint PPT Presentation

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