Good day everyone, and welcome to this RHC Technical Assistance conference call.
At this time, I'll turn the conference over to our host, Mr. (Bill Finerfrock). Please go ahead, sir.

(Bill Finerfrock):

Good afternoon, everyone. I apologize. We've had a little bit of a technical difficulty. We're getting started a few minutes late.

Welcome to the fifth in a series of Rural Health Clinic Technical Assistance conference calls that are being sponsored by the Office of Rural Health Policy in conjunction with the National Association of Rural Health Clinics.

Today's topic is "RHC Billing: Common Questions and Common Mistakes." Our speaker today is Ron Nelson. Ron has provided management, financial and consulting services to hundreds of practices throughout the United States. He's the co-founder and past president of the National Association of Rural Health Clinics, and is a frequent speaker on issues of reimbursement, managed care and health system development.

Today's program is scheduled for one hour. The first 35 minutes will consist of Ron's presentation and the remaining 20 minutes or so will be dedicated to questions and discussions.

This call series, as I said, is sponsored by the HRSA Federal Office Rural Health Policy and it's intended to provide information and resources to the Rural Health Clinics community in a very cost effective efficient manner. At the end of our presentation, there will be - the operator will come in and explain how you are to queue up to ask your questions. It is an open mike format. When you're open - when your microphone is open, you'll have an opportunity to dial on and get ((inaudible)). We'll take as questions as we can during that period.

You should have been able to access and download a copy of the presentation from the Web site at ORHP. And a transcript of this call will be made available at some point after it's been typed up and reviewed by the speakers.

With that having been said, Ron, we appreciate your taking the time to be with us, and we welcome your presentation.

Ron Nelson

Thank you, Bill. I appreciate the opportunity to present today on this topic of understanding billing in Rural Health Clinics and the common mistakes and questions. Certainly, that seems to be a common theme in billing issues related to Rural Health Clinic services.

Having said that, I think it's important to note that this program historically was designed to provide for a cost based reimbursement all inclusive rate payment to Rural Health Clinics to ensure that care would be provided in those rural areas. And subsequent to that initial legislation, there have been many changes, which have rather than add to simplicity, have made it more complex and subsequently adding FQHC services as a RHC type of services and then the subsequent provider base issues, which were originally those clinics attached to hospitals and now have other subclasses such as those hospitals with more than 50 beds, those with less than 50 beds, and certainly critical accessed hospitals. Having said all that, it creates lots of questions and I'm sure there are many heads nodding going, yes, we're experiencing them.

So, what I hope to do today is to go through some of the major issues that we continue to see in the program, and then we'll have an opportunity for some Q&A and the opportunity to discuss with folks specific questions they may have.

First of all, I think it's important to understand that this is a program that is really the delivery of part B services using a part A methodology. And the Rural Health Clinic Services certainly is defined under the Medicare program as those traditional services as the point of entry into primary care, which would include services of a physician, the services of PA's, nurse practitioners, certified nurse midwives and psychologists, social workers, and those services or supplies that might be incident to any of those individuals.

And I think it is important to note that sometimes there is confusion that exist over what the term incident two means because while it's definition is the same, its application in the fee for service rural under part B, is somewhat different than the discussion we used in the Rural Health Clinic Program, even though the basic principles are the same, it does not apply to the PA, nurse practitioner services as an incident to service for the physician, but rather applies to incident to services that are incident to any of those professionals, including the physician, the PA nurse practitioner, certified nurse midwife or behavioral health specialist.

It is important, I think, for us to also recognize when we're talking about the RHC program, that there are part B services that are provided in Rural Health Clinics. Everyone generally I believe has some pretty good understanding of what RHC services are, and that those are built to the RHC fiscal intermediary.

But the Part B services, in time, become somewhat confusing. I think it's important first to understand that services that are generally going to be provided in the hospital, such as inpatient services, visits to the emergency room and outpatient department where a professional component or physician service as a PA or nurse practitioner or certified nurse midwife are provided in the hospital would be considered to be a part B service and would be billed to the part B carrier and would not be an RHC service.

There are probably some exceptions to that. The only one that I can think of quickly is where a patient converts from a hospital inpatient to a swing bed where they then become really a long-term care patient, and we'll talk more about that later, and that's where a patient changes from being a part B to becoming an RHC service.

The other area that frequently is discussed in there continues to be questions which we see on the list serve where people ask the questions about laboratory. There are six required tests that are identified in their RHC program that you must be able to provide at the RHC. Regulations do not require that you actually provide them, but that you must have the capabilities to certainly provide those.

Laboratory have also - has also been identified as a part B service. And as such, you have to have the appropriate mechanisms to account for the cost associated with the delivery of the laboratory service. And in the laboratory, generally there are not a split of a professional verses a technical component. Therefore, the entire lab cost is generally going to be carved on the cost report and build as a part B service to part B as required by some changes which occurred in the last few years.

The diagnostic test that might be provided in the office in a Rural Health Clinic, things like pulmonary function studies, and other kinds of diagnostic studies might include a (holter) monitoring. The technical component of that particular service must be split and the technical component is build to part B, and if the professional component is a service that's provided by an RHC provider in terms of interpretation and the ordering and interpretation of that test, that would be included and become a part of the RHC visit and would be split from the technical component, which would then be billed to part B.

One of the areas that there has been a recent interpretation that I think is going to cause a fair amount of question and concern is under the area of reading of x-rays. Previously, x-rays that are generally provided in Rural Health Clinics have been read by radiologists, which is a standard of care issue whereas it's appropriate to retain a radiologist to provide the overview in reading an interpretation or report on an x-ray that has been taken.

In that normal scenario, radiologists are frequently, and in most cases not onsite within the four walls of the clinic. They're generally in their radiology departments, and the films are couriered to the radiologist. It has been the general opinion, and I believe the general practice, that radiologists' fees were considered to be the professional component of the interpretation of that x-ray, and therefore, would be included within the RHC cost even though there is no separate way or has been no separate way that has been identified previously to build for those.

And so recent opinions we've been informed by CMS that the radiologist fees cannot be captured within the RHC cost unless the radiologist is actually reading the films onsite within the four walls of the clinic. If the radiologist is reading those films offsite, it then becomes an issue of now splitting the bill and having the radiologist build for those x-ray services or having the radiologist reassign the billing of those services to the RHC, and the RHC would have to bill them to part B to capture the professional component of that x-ray.

It is still consistent and correct that the technical component of the x-ray is clearly to be billed to part B. The issue that has recently arisen and has raised some concern is how the radiologist fees are to be handled, and the ability to split them has been documented and certainly articulated from CMS. They're now, I believe, is going to be some questions about how that will be practically applied in the typical rural community given that radiologists frequently are not going to want to be doing the billing. They're some sharing of billing information issues, and then there's the issue of reassigning an additional billing to be done by the clinic to bill for the radiologists fees.

That is one that people need to be aware of and further research if they're providing radiologist fees, but that is one that people need to be aware of and further research if they're providing radiological services in their clinics.

The next point that I think is important, excuse me, in talking about Rural Health Clinics is by nature, by regulation and statutes, Rural Health Clinics physician assistance, nurse practitioners and certified nurse midwives. The frequent question that is presented is, do we have to use - do we have to a (UPIN) number for those individuals? And this is another area that we see some of the conflict that can exist within the policies of a Medicare between programs. Example, Part B and the Rural Health Clinics Program.

Correctly done, a PA, nurse practitioner or certified nurse midwife who are providing services to a Medicare beneficiary and sending a patient, for example, for a diagnostic study, the regulations require that the (UPIN) number of the individual who is ordering the study must be supplied. That individual must also supply appropriate diagnostic information to the facility that's performing the testing to assure that the appropriate information is there and can be billed and accounted for.

As such, it seems appropriate that PA's, and nurse practitioners and CNM's would have an appropriate (UPIN) number when providing services within Rural Health Clinics. I hear often from Rural Health Clinics, well, we just use the physician's (UPIN) number, and while that is possible and that does generate payment, I think to technically be correct, and for the purposes of any type of monitoring, you should use the (UPIN) number of the individual who is in fact providing the service or ordering the particular service.

Another area that has recently come up and is going to be a greater and greater issue in the future is the Medicare Advantage Program. Many of the Medicare Advantage, specifically, some of the fee for service programs as well as the managed care programs, have not really addressed how they will - how they will utilize or they will account for services provided by PA's, nurse practitioners and certified nurse midwives. This raises a question for the clinics that they need to - and the discussion with Medicare plans to ask questions about how these individuals will be accounted for in the billing process and in the payment process given that all Rural Health Clinics will have one or more of these individuals practicing in their practice.

Another area as we see greater and greater emphasis again on Medicaid Managed Care is to talk to the Medicaid Manage Care Plans about how to ensure that they're accounting for and recognizing the services they're provided by PA's, nurse practitioners and certified nurse midwives within the Rural Health Clinic. Because frequently, it is recognized that they will cover a service that is forgotten, and the discussion, and the policy discussion regarding how specifically to deal with PA's, nurse practitioners and certified nurse midwives.

Moving forward, some of the areas that we see create continuous questions and people continue to have questions include areas like the vaccines. Vaccines in Rural Health Clinics are to be paid for Medicare beneficiaries, the flu and ((inaudible)) vaccine are to be paid for on their cost basis. There are some questions that have come up regarding Medicare Advantage and how these will be paid or, and I think that is being pursued to address this and try and identify answers as to how the Medicare Advantage plans will for these vaccines. But it seems that the regulations are clear that these are paid for on cost.

Billing for procedures for things such as endoscopies, biopsies and surgical procedures raises some significant issues and concerns within the Rural Health Clinics community. One of the things that has been identified within discussions at the policy level and reimbursement discussions include the issue of co-mingling, and the concern that a fee for service practice should not and in fact, cannot co-mingle services between the fee for service and the cost based service of a Rural Health Clinic.

As such, we frequently hear from people, well, I want to carve out the procedures for biopsies because they're high reimbursement areas, they're high cost issues or services and if we accept our rate of $70 as an example, we're getting much less than we would get under fee for service.

So the question that is frequently discussed, is can we carve out those procedures? Well, I believe there is a way that that can be done. I caution practices often, if they're going to look at a time that they're going to carve out to do non-RHC services, they need to be careful in identifying, number one, posting hours that you are not functioning as an RHC, two, being clear that there's a methodology to allocate the actual cost associated with those non-RHC services and the provision of that generally a dedicated space and also identifying separate staff that are going to be providing those services, is a critical piece in looking at the potential for carving out services.

I would also advise people, if they're looking at some of the higher cost services such as endoscopies and biopsies, it may be more appropriate to look at providing those within your hospital in an outpatient department. And as such, the hospital is able to capture it through their (APC's) a facility fee, and you would then be able to capture under part B, a fee for the purposes of providing that particular procedure. And it may be simpler to look at trying to do that in the hospital.

Recognizing some of you may be many miles from a hospital and cannot do that, if you're doing a large volume, you may look at some mechanism to try and identify non-RHC time. The key on this issue of billing for procedures and billing for services that you may want to carve out is to have an appropriate methodology to clearly allocate those separate costs and services.

I'd like to address just for a moment, the issue of Medicaid, because we're seeing again greater and greater emphasis on Medicaid and specifically looking at Medicare Manage Care as the governors are looking more and more ways to contain cost in their states. The Medicaid Program does cover the core services that are generally covered under the Medicare state plan. The states have the opportunity, if they choose, to add other services to be covered RHC service. The state has also had the option to elect to use the PPS methodology where a rate was determined based upon an average of 99 and 2000 or for new clients based upon the average rage of clinics in a particular rate or region.

The election for the PPS rate allows states the opportunity to pay a fixed rate that has been adjusted based on the EMI adjustment on an annual basis. Unfortunately, that has created some difficulty for some of you in terms of rate setting is the states tend to not set the rate until somewhere - at times anywhere from 10 months to a year after its been adjusted by Medicare, and therefore, it allows for some significant loss revenue and is something that you need to consider.

For those of you who are in full cost reimbursement in Medicaid, it is important to continue to ensure that you understand what those core services are that Medicaid is covering in any other ambulatory services that may be included within the Medicaid cost and the setting of your rate.

More importantly, I think it is also necessary for you to begin to analyze the impact that manage care may have on your RHC services and what opportunities you may have actually in participating in manage care to realize some additional return over and above your cost via withholds that may occur, for example, in the manage care plans. And those are things that you should look at when analyzing the impact of Medicaid on your Rural Health Clinic.

I think it's important to talk, at least for a moment, about behavior health services, since this is a significant opportunity to meet an unmet need in both the rural underserved areas and specifically for elderly population.

The RHC Program allows for the services in behavioral health of a clinical psychologist for PHD for Medicare, a clinical social worker masters prepared for Medicare patients to be a covered service under the Medicare program. The 37-and-a-half percent mental health limitation still applies to the behavioral health services for therapy provided by these individuals. It is important to remember, however, if you're doing behavioral health services, that the initial visit, which includes - which is the diagnostic evaluation by the patient is supposed to be paid at a 100 percent and not apply the mental health limitation.

Another area that I think is confusing because of the way that the RHC manual is written is that it is been their opinion that behavioral health services must be provided within the four walls of the facility in order to be a covered service. In other words, it is not allowed for a clinical social worker or a psychologist to provide services at another site and bill them through the RHC, but they must be provided within the four walls of the clinic.

Next area just briefly to touch on, I think, because of the greater and greater emphasis on (TeleHealth) is (TeleHealth) and the opportunity to build for that. It is - it is outlined in the slide that's in your presentation. It talks about a billion a (Q) code, which is paid separate from the all-inclusive rate and is actually paid above $20, which unfortunately is paid on 80 percent. It is to be build to your (fiscal) intermediary and paid by the (fiscal) intermediary for transmission of the real time (TeleHealth) services. Meaning that you cannot store and later transmit and consider that a (TeleHealth) service.

Back to the issue of skilled nursing facility and (swing beds), you frequently hear questions from people regarding the billing of long-term care, specifically it's important to note as of January 1, 2005, all long-term care visits provided by an RHC provider to an RHC patient should be considered RHC services and billed to the (fiscal) intermediary. A question that frequently comes up has been swing beds in a hospital. Once the patient is moved to a swing bed status, they then become a long-term care patient are billable as a RHC service.

There have been questions raised regarding the (periodicity) schedule required or allowed under the swing bed and long-term care. It is a requirement that the patients are seen every 30 days, but not less than 21 days. And frequently, the question is asked, can a PA or nurse practitioner fill that need? And, yes, a PA and nurse practitioner can make that required visit, but it cannot be done in less than 21 days. Generally there is an every 30-day visit.

What frequently occurs is visits occur more often than every 21 days, and many times that's because there's a medical necessity for that patient to be seen because of an acute illness. If, however, the documentation that shows the medical necessity, it's not going to be paid as an allowable service. The medical necessity still applies that in order for more visits, more frequently than every 30 days and a minimum 21 days to be approved, there must be medical necessity to show the need for that patient to have been seen with some type of an acute illness or problem that required an intervention of a PA, nurse practitioner or physician to address that.

We have already addressed the issue of billing procedures, and again, let me just caution those that are looking at billing procedures separately, to look at a methodology that allows for appropriate allocation of the costs.

One of the more common questions we also hear is the issue of billing for crossovers, and how do we appropriately bill for those patients that have Medicare as primary and then have secondary insurances. And frequently, what we hear is that the secondary insurance looks at an EOB and sees that the patient - that the clinic was paid over the (fee screen), therefore, they do not believe that they have the requirement to pay for the co-insurance amount.

I believe there is an issue here of contractual obligations. Frequently the secondary insurers sign contracts to provide the coinsurance coverage for Medicare beneficiaries. And doing so, they agree generally contractually to cover those services that are approved and covered by Medicare. It also requires that they pay the co-insurance amount. What we have frequently is that it's a unnecessary to point out to the secondary insurers that even though the (paid screen) or the payment was above the fee screen, that payment is an all-inclusive rate and does not represent fee for service payment, therefore, they need to look at the co-insurance amount in order to determine how much is to be paid.

A second area that we find is that there's confusion when you use the billing number or (UPIN) number of a non-physician practitioner, such as a PA or nurse practitioner, that frequently then if those individuals are not credentialed in the (Medigap) or secondary insurance, that they have no way to pay that, and it has to be manually re-billed then under the physicians name.

Those are all issues that people deal with. You have to look at your own situation and find the most effective way to make sure that you're getting paid for those claims because it is necessary for those secondary insurances to cover the co-insurance amounts and deductibles as they have committed to contractually in their contracts.

There are obviously some additional issues related to provider base clinics and I want to at least address some of the unique differences that exist in the provider base community. And one of those, I think, is that generally those services that are provided in the clinic, are unique differences that exist in the provider base community.

And one of those, I think, is that generally those services that are provided in the clinic are billed as a Rural Health Clinic service. However, those services that are provided that are laboratory or x-ray, are considered to be hospital services and must be billed as a hospital provider type.

There are some unique situations that exist in critical access hospitals related to the fact that critical access hospitals receive full cost for the services they provide to Medicare beneficiaries. So, for the x-ray and lab services that are provided by an RHC, that is attached to the critical access hospital, they would be eligible to get the full cost reimbursement through the critical access payment methodology. For those Rural Health Clinics that are attached to clinical access hospitals but physical distant or physically off the campus is a different provider, there's a different bill type, and in fact, those are paid on the fee screen for that critical access hospital, not at full cost.

So for those of you who are critical access hospitals that have provider based clinics both onsite and offsite, you have two different types of reimbursement methodologies for those ancillary services such as laboratory and x-ray.

I think it is important before we go to Q&A, to just review some of the basic concepts that have to be considered in this program. That is, to identify what constitutes a visit which is a face-to-face encounter between a PA, a physician, nurse practitioner, nurse midwife or a psychologist or social worker.

Frequently we have had questions regarding the issue of two visits on the same day, and there has been lots of controversy, certainly on the list server over some comments that I believe I have made regarding two visits on the same day. And I would like to review that scenario that was presented whereby a patient is seen by a PA or a physician in a Rural Health Clinic with a complaint and a diagnosis of acute abdominal paint. That patient now requires a surgical evaluation and within that Rural Health Clinic also practices a general surgeon.

The patient is then seen by the general surgeon who now is going to do a surgical consultation. The surgical consultation constitutes a distinct and different service as evidenced within the Medicare benefit's policy manual, it is identified under section 50.5 that a consultation is in fact a separate and distinct service payable the same as it does under concurrent care, which his contained in the same section.

So in that scenario, you have the need and is one of the few exceptions that might occur for two visits on the same day where a consultation is occurring as a result of an initial problem. Generally, however, visits for the same problem on the same day do not constitute two visits, but constitute one visit.

One might ask a question how to bill for such a service where you believe you have two distinct services. My suggestion would be to talk to the (fiscal) intermediary. I would generally probably submit two distinct bills recognizing they will immediately be kicked out and would have to be manually reviewed which will determine whether or not there was coverage.

I think it is important, also, to review the issues of preventative care that are covered under the program. Currently, Medicare has established guidelines for prevention of breast cervical cancer, prostate cancer screening, colon cancer screening and bone mass density screening in those areas, it is important to understand that if a visit is required to perform those services, that visit becomes an RHC service. The laboratory portion or technical portions of any of those services will be considered lab services and would therefore be - or be diagnostic services that would be billed to part B.

However, as an example, to do a pap smear requires an in fact visit. The visit to form the paper smear becomes an RHC service, the laboratory study that's necessary for that service to review the slide and given an interpretation is considered to be a laboratory service.

I believe it is also important to recognize that at times, there may be services that provided on days when we do not necessarily see the patient, and the recommendation has generally been to attempt to attach to those a visit within a 30-day window. Again, I would advise that you communicate with your (fiscal) intermediary to determine that.

I'm going to move along and review the issues of Medicare, pneumonia and influenza vaccines and then we will move to answering questions.

I think it's important on the pneumonia and influenza vaccines to recognize that you are to be paid full cost as a statutory requirement. That is to be determined then by a cost finding that is done on the cost report, but you must create a log for those patients. They should not be billed to your part B carrier, but should be in fact, logged creating - log with a data of service, the patient name, their Medicare number and the vaccine that is given. It's critical to maintain those logs.

Many of you are, I'm sure, looking at your phones and saying, wait a minute, what about Medicare Advantage? Those particular plans have to figure out a way that they are going to pay for your vaccines somewhere near or at your cost, and that is going to be one of the challenges that I think we face with the Medicare Advantage Program.

Finally, I want to - before we open up to questions, point out that there are some bonus payment services or opportunities that exist for the non-RHC part B services we provide, and there are significant numbers in many clients of non-RHC services or part B services that are provided.

The opportunity for the bonus in the geographic area (HPCS) continues to exist at 10 percent, but there's a new category referred to as the physician scarcity area and the physician - specialty physician scarcity area, which adds an additional potential for five percent bonus. These bonuses are to be paid automatically. They apply only to services provided by the physician, not the services that would be provided by a non-physician provider such as a PA or nurse practitioner.

If you have questions and want to find out whether you fall within one of those areas, you can - you can identify that on the site that is listed in the slide in your handout.

I believe we've now gone a little over 30 minutes and it's time for us to open for Q&A. I would like to say that what I have tried to today is highlight some of the areas that we have to continue to look at, we continue to hear questions about. It's also important to note that we deal with several (fiscal) intermediaries in this program. We deal with multitude of part B carriers. We also deal with a multitude of provider based (fiscal) intermediaries. And it is sometimes different opinions that apply what we're trying to do today is to address what the general regulations look at in terms of the Rural Heath Clinics Program and the requirements for billing and coverage under the Rural Health Clinics Program.

Operator, I think we're ready now to go to Q&A.

Operator

Thank you, Mr. Nelson. The question and answer session will be conducted electronically. To ask a question, please press star one on your telephone keypad at this time. We'll take as many questions as time permits and proceed in the order you signal us.

(Bill Finerfrock):

OK, operator, before we open the lines and start, I just want to - when our callers are - when your line is open, if you could identify yourself by name, the location that you're calling from and also whether or not you're a provider based or independent is relative to a provider base or an independent Rural Health Clinic.

Operator

A voice prompt on your phone line will indicate when your line is open to ask your question. Please state the required items. Once again, star one to ask a question, and we do have several in the queue.

(Bill Finerfrock):

OK, first question.

Female

(Peter Sokoba), (Life) Medical Associates in Elizabeth Town, North Carolina.

Male

OK.

Female

Welcome to Medicare physical, we are not being able to be paid by (River Bend), and we wanted some help with that.

Ron Nelson

Have you - have you spoken to (River Bend)? That is a covered service.

Female

It most definitely is and we have spoken to them. We even got the book that they put out about the preventative services, but we are not getting paid for our office visits.

Ron Nelson

Have you spoken to their billing representative to understand why you're getting the rejection?

Female

They're not able to tell us why we're getting a rejection.

Ron Nelson

OK.

Female

We're using the appropriate revenue codes. They obviously don't recognize the CPT code that was assigned because that, of course, was just for part B. And we're billing at the rate and we're using the V70 which indicates it's a physical. We're doing everything that we think we're supposed to, but they're still coming back as not being paid.

Ron Nelson

And you've spoken to the billing representative at (River Bend)?

Female

Yes, we have, on several occasions.

(Bill Finerfrock):

What did they tell you?

Female

That we're not doing it right, but they're not able to tell us what we're doing wrong.

Ron Nelson

Well, in that situation, what I would do is I would suggest that you ask them to put something in writing to you as to specifically why the claim is not being paid. I'm having a hard time understanding - I certainly hear your frustration that you're not getting paid, but something is not being done right in this process that has necessitated the rejection you're getting. Because I think everyone has agreed that the Welcome to Medicare Physical is a RHC service and should be covered and paid as an RHC visit.

So what I would suggest is you contact (River Bend) and do that. I would ask them to give you something in writing as to specifically why that's not happening. If you're not getting any answer at that point, then I would suggest you contact the National Association. We can certainly contact representatives at (River Bend) to try and get that answer for you. But without seeing detailed information including what your rejection has identified as the reason it's being rejected, it's difficult probably to come to a solution on that issue for you today.

Female

But what we are seeing is they're saying it's a non-covered service, and of course, we know that's not true again.

Ron Nelson

That's correct. So what I would suggest is you ask them to identify that since it is a covered service in an RHC, why is it not getting paid, and if you're not able to get that resolved, then I would suggest you contact the National Association, and we will forward that on to folks at (River Bend) who had been very helpful in trying to resolve these questions.

(Bill Finerfrock):

Why don't you go ahead and give me your name again and phone number.

Female

Jennifer Coble.

(Bill Finerfrock):

Coble - and give me your phone number, (Jennifer).

(Jennifer) Coble

910-862-5500.

(Bill Finerfrock):

I'm sorry, 910 …

(Jennifer) Coble

862-5500.

(Bill Finerfrock):

I'll call you and we'll try and see if we can't set something up to try and figure out what's going on here.

(Jennifer) Coble

OK. Just an addendum to that, this Welcome to Medicare Physical is subject to the deductible and 20 percent of that, am I correct?

(Bill Finerfrock):

I'm not sure off the top of my head.

(Jennifer) Coble

I believe it is, and I was just wondering, you know, you're able to bill for a physical - to bill the patient for a physical with the difference in the rates, and the patient pay that …

(Bill Finerfrock):

Right.

(Jennifer) Coble

… actually have less cost for them themselves in that regard than it would be if we just billed the physical, because they'd have to pay $100 plus the 20 percent.

(Bill Finerfrock):

You're right. It's cheaper for them to do it that way.

I'll call you and we'll try and figure out what's the problem here.

(Jennifer) Coble

OK, thank you.

(Bill Finerfrock):

Next caller, operator.

(Megan)

Yes, my name is (Megan), I'm calling from (Dickinson County) Health Care System, we have a Rural Health Clinic - we have a nurse practitioner that wants to go into the Rural Health Clinic and do diabetic teaching. From what I understand from what you've been saying, that would have to billed to Rural Health not to part B?

Ron Nelson

Diabetic teaching, unfortunately, is not a covered service in the RHC for the purpose of billing. It is certainly a service you can provide within the RHC, but your way to capture the cost of that is going to be is through your all-inclusive rate. It's not a separately billable service within the RHC.

(Megan)

OK - this does include prescription management and …

Ron Nelson

But I understand that, but there is a very specific guidelines for what constitutes diabetic teaching, and there's also medical necessity requirements that apply. And it is important to recognize that while I see diabetics every day, I treat a lot of diabetics, what I do when I see those diabetics has to do with medical management, and it's medically necessary for the management of their diabetes, there are - and while I could perform the diabetic education portion of that, that has very specific guidelines that are required, and that is not a separately billable service.

If you have a medically necessary office visit performed by that nurse practitioner and as a part of that visit includes education regarding the diabetes, that's a covered service under the RHC program. But the key here is that needs to be a medically necessary service.

(Megan)

OK. Thank you.

Ron Nelson

You're welcome.

(Bill Finerfrock):

Before we go to the next one, let me ask one that was e-mailed in ahead of time. It's from (Fahaz Oden), "Please explain how chiropractic services performed by a licensed chiropractor provided in a rural health clinic should be billed to Medicare? Are the services only those which are allowed by Medicare, i.e. the manipulation of the spine?

Ron Nelson

Within the RHC program, you're going to be limited to the services that are provided to Medicare beneficiaries, no different than any other Medicare program. You can't bill for a service that's not a recognized Medicare service.

I have not seen people billing for the Medicare portion of chiropractor care in an RHC. I have seen people do that on the Medicaid side with success. But on the Medicare side, while Medicare does recognize that individual as a chiropractic physician, while I believe it would be a visit, I believe you need to communicate directly with your Medicare FI to find out how they would want to bill that and recognize that. And I do believe that your statement in your question is correct. They are only going to provide those services that the chiropractor is authorized by state law to provide to Medicare patients and authorized under Medicare policy, which is generally the manipulation of the spine.

(Bill Finerfrock):

OK. Next caller from the phones.

Operator

Caller, your line is open. Please go ahead.

(Kara)

This is (Kara) from ((inaudible)) County Health System (Metro) North Dakota. I would like to know if the (swing bed) that visits are billed under the UB92.

Ron Nelson

The (swing bed) visits are considered to be RHC services when the patient becomes a - when their status is changed from acute care to (swing bed). At that point, it becomes an RHC service. There is still a requirement for any visits that are provided beyond the 30-day required visits that there be medical necessity for those visits. But they are required - they are covered visits that are paid under the RHC program, and they can be provided by the physician, PA or nurse practitioner.

(Bill Finerfrock):

I'll take another one from our e-mails.

"When we see a patient", this one comes from D. Russell, I think it is - David Russell, "When we see a patient for a fractured care, how should we bill this? Do we bill a global fee for the initial visit and no charge for follow up, or should we bill for each face to face encounter with the appropriate (ENM) code? Should we charge for supplies and casting?

Ron Nelson

That's an interesting question and I just actually read some information about this regarding current opportunities or guidelines for fractured cares. Now apparently it's possible that you can choose whether you want to bill global or you want to bill on a per visit basis and components of the fractured care. Previously, it has always been recognized that the global fee would apply.

There is, however, some concerns in the fee for service rural as whether or not they're going to separately identify and allow billing for cash supplies. As an RHC, you would bill that as a face to face encounter. You would determine what your charge is going to be and you would then collapse that into the revenue code and bill for the service.

Given that fracture care frequently requires multiple visits, it may be in your best interest to bill that on a per visit basis rather than a global, which would then allow you to capture a per visit all-inclusive rate for each visit. I believe you need to do that analysis within your clinic to determine what is the best way.

The important thing here regarding the charge is that if you bill the patient a global charge, and the patient is then appropriately billed their 20 percent, you can't bill a subsequent visit because you've billed a global. If you bill them on a per visit basis, you have the ability to capture the 20 percent of then that per visit basis with each visit, and subsequently then determine whether you're doing as well during the per visit or the global.

I think this is one that has changed recently in terms of the opportunities and it's actually changed to allow greater flexibility for Rural Health Clinics and how they're going to capture those particular charges.

(Bill Finerfrock):

Next caller from the phones. Next question.

(Scott Ford)

OK, my name is (Scott Ford), I'm from the medical center in (Alberton), Georgia. We are a free-standing Rural Health Clinic, and my question is this, let's say that we have a situation where a patient has private insurance primary and Medicare secondary. The issue for us comes where we are billing the secondary a portion. Is it OK - is it possible that you could bill the secondary portion to Medicare part B if it was otherwise an RHC service, or should that be going to the part A carrier?

Ron Nelson

Generally if it's a Medicare secondary coverage, you have a primary private insurance and then Medicare kicks in as the secondary, you need to bill that to the RHC. And the reason is that you're billing to the RHC program is the way your cost report works is that you're assured - let's assume as an independent, you're at $70 for your rate. And let's say that your private insurance pays you $50 on that, and the you bill the secondary for Medicare and maybe they give you $10. Whatever they give you for the secondary portion, they may only adjudicate the claim and show it as paid without giving you actual cash. The bottom line is you're still due the full amount of your all-inclusive rate or 80 percent of your all-inclusive rate, and that will be reconciled in your cost report.

What will happen is the private insurance payments will be deducted, but the balance that's due for Medicare up to your full cost, is still due to you. If that's provided also by a Rural Health Clinic provider during Rural Health Clinic hours, you cannot bill it to part B because that's an RHC service that's been provided to an RHC patient generally during RHC hours. So there's really no way to separate that and bill that to part B.

(Scott Ford)

OK, well I - we had - we had just talked with several others from different clinics around the nation that had said that they had just, you know, had run into so many problems trying to submit the claim to the (fiscal) intermediary. So, in other words, what they were doing is they were just sending it to the part B carrier as opposed to the part A carrier.

Ron Nelson

I can tell you that with a fair degree certainty that you should not be billing the secondary claims to part B because that is an RHC service you provided within the Rural Health Clinic. Now how to get the FI to recognize a Medicare secondary payer, that's one of those things that the minute people hear MSP, they start to get a headache. I'm sure you've experienced the same thing.

I think if - and if that's become an issue, what we may need to do is help you in terms of communication with the FI to help understand what issues might exist regarding the Medicare secondary payer, and what kinds of problems may exist.

(Scott Ford)

OK. Thank you very much.

Ron Nelson

You're welcome

(Bill Finerfrock):

Take another call, operator.

(Paula)

My name is (Paula) ((inaudible)) Hospital, we're provider-based, and my question has to do with the covered preventative services. The way that we need to bill on the UB, there's only the revenue code. So you don't have the (HIPCS) code identifying the service. If the patient has had too many or too many in a shorter period of time, how does the Rural Health intermediary know to deny? And would it be a problem to bill those types of services to the carrier instead?

Ron Nelson

Well, first of all, you cannot bill to the carrier for services that are RHC services. That's, I think, that's fairly clear. And I think sometimes people want to believe that well, if the FI won't play it for us under the Rural Health Clinics Program, then we'll bill it to the carrier. That's the wrong approach because that's not necessarily - that's not a part B service. It's a RHC service.

If the issue is your - and I'm - as I'm understanding your question, is you're wanting to know how the FI knows the periodicity schedule as it relates to Medicare for what isn't allowed preventative service. Is that your question?

(Paula)

Yes. Because they won't get the (HCPC) to describe it.

Ron Nelson

Well, I can't give you an answer because I don't know how their systems are set up, but they are required to in fact, have a mechanism and a communication to determine what is in fact an appropriate preventive service based upon Medicare's periodicity schedule. For example, for routine prostate cancer screening, pap smears, all of those things.

So, are you experiencing a problem where you're finding they're rejected because of the periodicity schedule?

(Paula)

Actually, we're afraid to bill these services because we're afraid we're going to get the whole encounter and then have it be paid inappropriately, and then, you know, have the money taken back.

Ron Nelson

Well, I'm not sure I would be afraid. That is FI's responsibility to determine whether or not that patient is eligible for that particular service in terms of paying for it. Certainly, we ask the patients - hopefully in many clinics, we're seeing patients with some continuity of care and as we're providing the care, we know that this patient has or has not had this particular service. That doesn't always occur, I understand. But I think that - I would encourage you to bill for those services. I would not withhold those services.

And certainly, you can ask the patient, have you had this particular service done in the last year, which then allows you to make some judgments about whether or not that fits into the periodicity schedule for that particular preventive service.

(Paula)

And if it did not, it would be a non-covered service?

Ron Nelson

Well, either that or if the patient has a diagnosis or a problem that in fact does require a service - I mean, for example, there's a periodicity scheduled for preventative services for prostate cancer screening, but then there may be a need, if the patient has now a diagnosis for prostate cancer, that there's - are obstructive symptoms or other reasons that in fact that patient's now being seen. So, you know, all of those things have to play into whether or not that becomes now a medically necessary visit verses a preventive service.

(Paula)

Right.

(Bill Finerfrock):

It looks like we have just a couple minutes left, so try to get as many questions in as we can. Another one from the phone lines, operator?

(Debra Sweeder)

My name is (Debra Sweeder), I'm with the Grand Lake Clinic, we're a provider-based clinic. We're fairly new to the Rural Health Care Clinic billing, and my question is, when you have a patient come in for either an injection or lab work that has been ordered by a different physician, how would you go about billing that if you didn't have a face to face encounter?

Ron Nelson

Well, first of all I'm assuming, and I shouldn't assume, you're talking about one of your Rural Health Clinic providers who said to a patient, the patient came in on Monday and was seen and said, I want you to come back on Wednesday for an injection of ((inaudible)) as an example?

(Debra Sweeder)

No. This is a patient that's going to see a specialist and has come in with either a prescription saying that they need blown drawn or because they live in our town, they want us to take over their injections. But actually, a different physician from a different group ordered it.

Ron Nelson

Something that might be (epogen) or one of those for in-stage renal disease. First of all, lab is part B, so that's not an issue. You could bill for the part B lab service. For the injection, what you have to determine is do you have a policy that allows the injections to be given in your office to be ordered by someone outside of your practice. I would submit to you that many practices won't do that without in fact making a determination.

Even though I may have referred the patient to the specialist, that the specialist says, you know, here. I want you to have an (epogen) injection every week, then what we would require is that the patient come in and is seen to determine that they need the (epogen) based upon the recommendation of the specialist and then the determination of whether and how we will administer that. We would then order that injection and we would attempt then to attach that injection to the visit, if it's not done on that day.

If this is going to be an ongoing process, people who are receiving meds that are injectable on some form of the periodicity schedule, just as a matter of good medical practice, should periodically be evaluated. And frequently, one of the areas we see where this doesn't happen with allergy injections. People are selling allergy serum, they come in, they say, well we'll just give them their allergy injections and I think that you have to be careful that you run some risk if you've not evaluated them with your own providers in the office that if you have an ((inaudible)) or something happens, you in fact are responsible for the administration of that vaccine when you give it in your office.

So I think what you need to do is consider discussing with your providers having the patient seen for a medically necessary periodic visit that documents what their medical condition is, how they're responding to the medication, any potential side effects that they're having, any interaction with any other diagnosis. That would then constitute I believe a medically necessary visit and allow you something to attach that injection to.

If there's no face to face encounter, you have no where to attach that injection and now way to bill it.

(Debra Sweeder)

All right. Thank you.

(Bill Finerfrock):

Operator, how many more people do we have in the line to ask questions?

Operator

We have 14.

(Bill Finerfrock):

Fourteen - I don't think we're going to have time to get to those. Why don't we take one or two - maybe we can go over a little bit here. We'll take - try and take one or two, if you've got some time, Ron?

Ron Nelson

Yes. And then - and then why don't we have them e-mail you their questions and …

(Bill Finerfrock):

If you don't get your question answered, we're just not going to have enough time, send it to info - info@narhc.org. we will get an answer to your question and we will get that send out either with the transcript or posted separately on the Web site.

OK. So we'll try and take one or two more, operator.

Operator

Thank you.

(Lynette Bird)

Hi, this is (Lynette Bird) from (Lakewood) Health System in (Staples), Minnesota ((inaudible)) Base Clinic, and my question is that if we have an RHC visit and during that RHC visit, the doctor does a non-covered service such as a routine foot care, trimming of nails, can we split that non-covered service and bill it to the patient's secondary insurance?

Ron Nelson

Provide a non-covered service - did you provide the patient an (ABN) uncovered service? That's the first step, I believe.

(Lynette Bird)

Say - no. If we …

Ron Nelson

Well, then you can't bill it.

(Bill Finerfrock):

Give a patient an (ABN) and you're provided a non-covered service?

Ron Nelson

You need to - you need to tell the patient if you have a Medicare beneficiary sitting in your office and you're going to provide a non-covered service, you need to at least provide that patient with notice that you believe this is a non-covered service, an advanced beneficiary notice that it's a non-covered service.

Now can you bill to the secondary? I think that's something that you would have to go to the secondary and see if they're willing to pay for that service as a - as a secondary insurance, and I certainly think that's a reasonable approach, but you have to determine what you're saying is doing the visit, you have a visit that you believe is a medically necessary service, and then during that same period, you perform something that's not a covered service, can you bill that separately?

And my concern is that you're providing RHC services with an RHC provider and then billing it to a non-Medicare insurer, I think you could do that, but I think that, you know, you have to be careful to make sure the patient knows that that's also not a covered service.

(Lynette Bird)

And so if we had an ABN, we could do that, we could bill it to the secondary?

Ron Nelson

I think you could as long as there's appropriate coverage that that secondary covers that particular service.

(Lynette Bird)

OK. Thank you.

(Bill Finerfrock):

This will have to be the last question, operator.

(Ruby)

This is (Ruby) from Central Care Clinic in Minnesota and we're independent based, and we have a question in regard to (home) health service and how to bill them. And also if they're doing other immunizations like vaccines or whatever besides flu shots and ((inaudible)) now do we bill those?

Ron Nelson

That's a good one. You've got two in for one here. Home health service are not an RHC service. Those are to be billed - those are not to be billed unless they're provided by a non-RCH provider outside of the RHC. So it's considered to be a part of the service that the RHC provider provides and it's not separately billable.

The vaccines - the question - if your question is can you bill the vaccine, you can bill the vaccine if there's been a visit. If there's no visit to attach to that vaccine to, and now we're talking outside of the ((inaudible)) and flu vaccine, and then there is no way really to bill for that vaccine as an independent HRC under the Medicare program.

You need to capture that within your cost, it becomes part of your all-inclusive rate and that's how you're reimbursed for it. There's no separate billable mechanism.

(Bill Finerfrock):

I want to thank Ron Nelson for his time and all of our participants here this afternoon. I also want to thank the opportunity to thank the Office of Rural Health Policy who makes these series possible.

As I mentioned at the outset, this is the fifth in the series of calls. We will be doing our next call in about a month. We'll send out information on the topic for that call, as well as the links to get the PowerPoint presentations.

As I mentioned, we will be making a transcript of this call available once it is produced and reviewed, and that will be - an announcement will be sent out as to its availability and where you can go to download that.

And for the future, we just want to remind folks to call in a few minutes ahead of time so we can try and get started. These have been very popular calls in terms of getting information out. If you have suggestions on topics, please feel free to send them to me again to the address info, info@narhc.org and we'd be happy to take a look at them for consideration.

We will probably be doing about seven calls over the next nine or 10 months in completion of these series. There are arrangements with the Office of Rural Heath Policy and I think everybody's been very pleased. We want to thank ORHP for picking this series up for another year, so we'll be doing these through at least September of 2006.

Thank you all for your participation and on behalf of the National Association of Rural Health Clinics, I'm (Bill Finerfrock), the Executive Director, and appreciate you're being with us this afternoon. Thank you.

Operator

That concludes our conference today. Thank you everyone for joining us.

END