Moderator: Bill Finerfrock
June 8, 2005
2:00 p.m. CT

Operator:

Good day, everyone, and welcome to the Federal Office of Rural Health Policy and National Association of Rural Health Clinics conference call. As a reminder, this call is being recorded.

At this time for opening comments and introductions, I would like to turn the conference over to Mr. Bill Finerfrock. Please go ahead, sir.

Bill Finerfrock:

Our speaker today is Jim Estes with Healthcare Horizon Services. Jim will provide explanation of the RHC annual evaluation required under the current regulations. It will also include an outline of the annual evaluation requirements so the participants will be able to conduct their own annual evaluation and be prepared for a recertification site visit by your state health department.

Today's discussion will include policy and procedure manual review, chart review, review committee makeup, utilization review, and more. At the conclusion of Jim's remarks, there will be a 15-minute question-and-answer period where you can pose questions and your phone lines will be open and the Operator will provide instructions.

I want to thank the Federal Office of Rural Health Policy for making this series possible and providing the resources so that individuals can participate free of charge and obtain this information. If you did not receive this through the e-mail alert system -- the new -- the system we use to put out the information, you can sign up to participate by going to www.ruralhealth.hrsa.gov/rhc and you'll be provided with a link.

In addition, if you have questions, feel free to send them to info@narhc.org. All questions and answers will be -- we'll make answers available to them and a transcript of this call will be sent out through the list serve probably within the next two weeks.

Jim, thank you for taking the time to talk with us today and we look forward to your presentation and it's all yours.

Jim Estes:

There are a lot of clinics across the nation that don't realize this is a requirement. In fact, I run into folks all the time that have never performed an annual evaluation of their rural health clinic. They just didn't know it was one of the rules and one of the requirements. Now, when they have their recertification visit from the state, then they discover, to their sadness, that they're missing something as part of that review process.

This report is an evaluation of the clinic's total operation. It's something that's required of all rural health clinics regardless of whether they're hospital based, freestanding, owned by a nursing home, a corporation, a doctor.

It makes no difference who the owner is: if you are a certified rural health clinic operating under the Medicare program, even if you never bill Medicare. Let's say you're a pediatric facility and you don't have any Medicare disability kids and all you bill is your state Medicaid program: you still have to comply with the Medicare rules of the Rural Health Clinic program in order to continue as a rural health clinic. This is what enables that pediatric clinic, for example, to receive their enhanced Medicaid reimbursement by nature of being a rural health clinic. Anything that you don't do that gets you out of compliance with the rules puts you at risk of losing your certification as a rural health clinic when the state comes by to perform their recertification visit.

The annual evaluation is not something that's expected at the initial certification because you haven't been certified as a rural health clinic yet. But once they come back with that re-certification visit, which can be every year -- generally, I find it to be about every three years -- three to five years, the Inspector will most likely ask for these evaluation reports. I know of some states that are just really very lax in doing those re-cert visits but you are liable -- you're open to having a recertification visit any time the state chooses to come by your part of the neighborhood and give you a visit.

So this is a report that you need to have on file, either a separate file where you keep it or put it in the appendix section of your policy and procedures manual. You should have a policy in your policy and procedures manual that stipulates you will do this. The policy should outline what will be in that report according to the codes of federal regulation. That's what we're going to go over more in-depth today and were going to squeeze this in to a 45-minute -- now, a 40 -- 39-minute context. But we'll make it, I assure you.

The annual evaluation is required, as I said, to be in compliance, and in particular, there are several different areas that you have to do. Every once in a while, I'll insert where I'm at on the slide so you can keep up with the PowerPoint. We're on number five at this point.

Basically, the regulations state that you have to carry out or arrange for an annual evaluation of your total program which includes review of specific areas, including utilization, review of clinic records, and policies and procedures among other things. Now, let's talk about what we mean by utilization.

Basically, you should evaluate the numbers that you gather for your cost report. Every rural health clinic should be able to get their encounters -- their visits as defined by Medicare: medically necessary, face-to-face visit between the patient and the provider, be that an NP, PA, CNM, MD, or DO, in the clinic, in the patient's place of residence, or in a nursing home. Those visits that you report as part of your cost reporting process are the numbers that you need to analyze. Look at them on a yearly basis. How many were Medicare, how many were Medicaid, and how many are all other payer classes.

Now, if you want to go onto more detail you can, but generally speaking, it's not that critical to know which insurance companies you have more patients with unless you're getting ready to negotiate a new contract with them, in which case, you might want to run your report specifically for each type of insurance company. Otherwise, the private pay, commercial insurance pay, no pay -- sorry, those are still there, always will be with us -- those types of visits--just kind of lump together in the "all other category". The amount of detail that you want to provide is strictly up to you. There's no stipulation within the regulations as to how you look at the numbers, just that you have to look at your numbers and see if utilization of the rural health clinic is reasonable for the community where the clinic is located.

This is a tool for you to use more so than for the government to look at. It tells you what your mix is on your visits re: does it still make sense for your clinic to be a rural health clinic. I've had clients where I would go in and do an evaluation of their program and find out that, wow, they've only got 20-percent Medicare and Medicaid, and of that, 15 percent of it was Medicare, only five percent Medicaid, and the difference in reimbursement was negligible. They took a harder look at it and in two cases in my experience, they've actually decided no longer to be part of the rural health clinic program because of situations in their state regarding Medicaid and other issues that came into play, as well as this patient mix issue.

If you have more than one location, you have to do an annual evaluation report for each site. Every rural health clinic has its own provider number and even if you might file a consolidated cost report where you take all the costs from each of those clinics and combine them in one cost report, the first page of that cost report will still list each clinic provider number -- each RHC number that's contained in those cost figures. If you have five rural health clinics in that you own or that the hospital operates or the doctor owns (or whoever), you have to have a separate annual evaluation report for each site. It has to be there in that office so that when the inspector comes by -- or at least within ready access where they can review that report and see that you've fulfilled that requirement.

What is the review of the clinic records? Well, this basically is a chart review. Now, I realize a lot of rural health clinics are already doing chart reviews, especially if you're part of a hospital-owned organization that is participating in joint commission, a (JCAHO) or what is commonly referred to as Jayco, where they have chart review as part of their QA plan. As a rural health clinic, you still need to do this no less than annually. In other words, once a year, you must stop and do some kind of a chart review. Now, there's nothing in the regulation that stipulates exactly what to look for but it makes sense that you're going to look for the things that Medicare requires for you to have in your chart.

On slide number eight, as we progress through the PowerPoint presentation, you'll find the beginning here -- at least, I think it's eight and nine is where we have that listed, the outline of what can be considered typical for a chart review. Obviously, you're going to confirm patient name.

Now, you know, that sounds like -- well, of course, you've got the patient's name on there. Well, sometimes it's a number and the name isn't revealed until you open the chart. The name's not even on the outside of the chart in some cases. I have found many times that we would have dictation or reports or information filed in a medical record that did not match the name on the chart. It may have been the brother or someone with a similar last name. It's very easy to get things misfiled when you're still with a paper system, so you're confirming the patient name and that it matches everything else in the chart -- that this is all related, in fact, to this one patient that's listed on the file.

Insurance class: you need to know if they're commercial, private pay, Medicare, Medicaid, self-paid, no-pay, whatever, and that class is usually revealed by a copy of their insurance card or a copy of their Medicare card, Medicaid eligibility (from your Medifax unit), or whatever you do to confirm their current eligibility status with the Medicaid program in your state.

Vital signs -- you know, I asked some folks at Riverbend, one of the RHC Fiscal Intermediaries (FI) some time ago if vital signs must be on an encounter report or part of the notes whenever they ask for notes to confirm whether an encounter was medically necessary. I asked them if those were missing would that automatically void that visit as being eligible to be counted as an encounter and paid a rural health encounter rate and the response I got really kind of surprised me.

What the vital signs do for them in their medical review, at least at the time I talked to them was it confirms that the patient was actually physically present, and in absence of those vital signs, makes them look at little closer at all the rest of the documentation. Well, you know, I don't know about everybody else out there today but I don't want the government looking closer at me -- any closer than necessary. Not that I'm doing anything wrong. It's just many times if they start looking closer, they'll find something that you thought you were doing right, and lo and behold, you weren't. You were making an error. It's best -- it's kind of like having a tax audit. I don't want them looking too close because if they look far enough and deep enough, I don't know, I probably made a mistake somewhere. Somebody's liable to find something.

The same is true with your audit of the chart. Should it trigger a closer look by your intermediary, then, as they look closer, there may be a host of things that they'll have suggestions for you to change or correct, which can be good as far as quality of care and working your program but it can also be difficult if there's money involved. So my comment about vital signs is, obviously, that needs to be part of the record and if somehow you're recording those but it's not becoming part of the permanent medical record, you need to change your system and make sure that you have the vital signs in the medical chart.

Signature, there are some specific requirements now from Medicare regarding signatures on patient charts, on the notes themselves and on dictation. I know a presentation at Riverbend made last year I believe at a national level, a copy of their slide that I used in my presentation says very clearly that initials will not be sufficient on medical chart notes. They need a signature from the provider.

While initials may work on your encounter form or on your internal mechanisms, when it comes for dictation or actual patient notes, they need to have a signature on them. And that brings us to the (soap) notes. Are they sufficient? What do they say? Do they meet what you, as a reviewer, feels is sufficient documentation to justify the level of coding that was charged out for that day's visit.

Now, you may not always go quite that in detail as far as pulling your remittance advice and comparing what was charged out and billed to the intermediary for that date and compare that to the notes. But generally, you should look at the SOAP notes. First of all, are they readable. If they're illegible, then, I'm sorry, it's not an encounter. In fact, the October 2000 Federal Register contains an article from the Office of Inspector General that makes it very clear that up-coding, down-coding, and eligible notes are considered a form of Medicare fraud.

So, if you've got providers working for you that are writing in some unknown language that you can't read, then your main emphasis here is they're putting themselves in a position of having committed fraud, not only with a payback of money but potentially other kinds of ramifications. They've either got to learn how to write or dictate and pay for dictation transcription services, or look seriously in electronic medical records so that you get out of the handwriting business on the notes.

In any rate, if the notes are there and they're readable, are they sufficient to justify billing it as an encounter. What you don't want to see is a nurse's note on the chart that says, "no problem, refill only" and then the doctor's notes just say, "hypertension, fill meds, see them in a year". That's not going to cut it. That's not sufficient. The notes need to be documenting what they did; why did that patient need to be physically present.

The way Riverbend puts it in their local medical review policy LMPR regarding rural health clinics is that they "lay hands on" the patient. What required that patient to be physically present, what did the doctor or the provider do that made it necessary -- medically necessary for them to have that appointment.

So those (SOAP) notes are very, very important. You should look at each date of service. You can make that as detailed as you want to. If you've got a QA plan going that compares orders for tests and then see if those tests were actually performed and whether or not you have a record of that in the chart, you can take it down that road if you want to. What I am providing today is again, simply an outline of areas that you might want to include.

Slide Number Six: patient information; has that been updated, is there any notation on there by the front office staff, their initials and a date, or something that shows that they've confirmed with the patient that this information is correct in their chart. A lot of times, there's a breakdown between the chart and the computer system. They might correct it in the computer system but not correct it in the chart and it's important that you have the same set of information in both locations.

Consent form: this is a consent to treat. There's a lot of different types of consents and releases out there in the field today. At one time, "implied consent" was considered sufficient. If the patient came in and said, "I want to see the doctor", then it was assumed they were giving that physician consent by nature of having asked to see him/her. You talk to just about any attorney and they're going to tell you that won't work in today's "lawsuit" society. I do not have any clients that don't utilize a consent-to-treat form and almost everyone I run into nowadays has it. Check with your malpractice insurance and see what they think about operating without something in writing that says the patient gives you consent to provide them with medical care.

I know in some states they require a special consent form if a PA or an NP is going to be providing that service--the patient has to give their informed consent regarding the use of the nurse practitioner or physician's assistant. I know Texas used to be that way. I'm not sure if they still are or not. But that's something that you may also want to check into. Generally, that's not an issue as long as the consent form is specific to your clinic and specific to the medical staff of your clinic. It needs to be stated on the form that it is for the "XYZ" (your clinic name) clinic and that it covers the medical staff and employees of the "XYZ" (your clinic name) clinic.

Many times when a clinic is purchased by another organization or you sell to someone else you continue with the same charts. In these instances, I find that old forms are in place and they just assume that since the patient gave consent and release (HIPAA , etc.) the first time around that it still covers them. No. You need to get new forms signed if there's been a change of ownership. These forms should reflect the new owner, otherwise, the new owner has not received permission to treat or release information or anything on that patient.

You also want to watch for the patient that's no longer a child. If they turn 18, then new consent forms need to be signed. New release of information needs to be signed. Also, you've got to be careful that you don't release information to mom and dad when they call regarding that 18 year old. You know, mom and dad may be paying the clinic bill but we don't have any right to get the information regarding their child's care because they're no longer a child; they're now an adult. So you need to get new forms. A system to "flag" this is helpful.

Now, I realize in some states there are certain consent requirements, especially in the area of STDs or in birth control and so forth. States differ in the ages for consent to be able to be given by the patient so you need to be aware of those differences and make sure that you're covered on the consent-to-treat and release the information.

Item number eight is the release-of-information form. This can all be on one sheet but you have to have separate language for each type of consent/release, HIPAA, etc. The patient may be signing once but all of the separate language for each type of consent, release, etc. needs to be specific. The most concise method I've seen is one that has it all on one page so you don't have the patient signing 15 things every time they come in.

Number nine: HIPAA notice of the receipt of your privacy statement. This is the standard phraseology that everyone's been doing now for a couple of years. I'm finding more and more that clinics are beginning to get a little lax in getting that notice signed by the patient, because they're at the point now where pretty much everybody that's coming in has been in since HIPAA went into affect and we had to get that notice receipt signed by the patient. And so, as a result, the front desk is slipping a little bit in many clinics in not confirming that it's there.

I've discovered a good method for making sure your HIPAA form is in the chart. I have a RHC client that has a little purple hippopotamus rubber stamp that they've made. The first time I saw that purple hippo stamped on the folder, I couldn't understand what it was for until they explained it to me. "That means that our hippo form is in the chart." So, basically, they took HIPAA, turned into hippo, and once they've got it done, they stamp the outside of the folder with that purple hippopotamus and they know that they've got the HIPAA form in there and don't have to even check any further. It's a real quick flag for them. Whatever system you use, you want to make sure the HIPAA form is there.

Number 10 is the Medicare lifetime signature language. That's not a specific form as much as it is language that Medicare wants you to have for the Medicare patient. It's a one-time deal. You don't have to do this every year. It's just a one-time signature. Many times when the (physical) intermediary asks you for notes regarding a date of service to confirm that it was medically necessary and fits the definition of an encounter -- many times, they will also ask for a copy of that patient's Medicare lifetime signature language. So you need to make sure this form is in the chart. The language for this requirement is available at my web site: www.healthcarehorizon.com

Number 11 and 12: the Rx log and the problem log. The decision on whether to not to utilize these forms is up to the clinic. I realize we're taking a little bit of time on this chart review piece but I've had an awful lot of questions on this. They're 11 and 12 on slide number nine. If you're a joint commission, you have to have these. If you're not, there's no requirement to my knowledge for a problem log or a prescription log. Now, obviously, you have to have somewhere in the chart where you've made your prescriptions and what they were. Generally, that's going to be in your (soap) notes.

If you want to keep a listing of chronic meds, where you've made changes, increased dosage, you know, lowered dosages, removed items from the list, that's fine. If you want to have a log for problems that would list everything they've ever come in for, every appointment, that's your choice. Or if you wanted to a chronic problem list, meaning asthma, COPD, hypertension, diabetes, whatever that are ongoing chronic problems, that's fine too but there's not a requirement for you to have that. Now, you need to be careful. If your policy and procedures manual says you're going to do this, then you better be doing it and you better be doing it on every chart, on every patient.

Many times, I'll find a client that has a prescription in a problem log and they're very lackadaisical about getting it done, mostly because it's not real clear in their policy manual who does it. Is the doctor the one that writes enters this data? Is it his/her nurse that writes in this information? Or is it the front desk -- who fills this out. So if you're going to do it, your policy and procedure manual needs to stipulate what it is and who enters the information. Are these forms a listing of every time they come for problems, or is it only a chronic problem, and if so, what does that mean and who puts it there.

If you're not doing it and your manual says you're supposed to then you'll be cited by your inspector, or you could be cited by your state inspector as being out of compliance with your own policies and that opens a door you don't really want to have opened because it creates a problem for you.

Number 13: the history form, and 14, is it updated. Every medical chart should have a medical history form that includes family and social history as well as the medical history of the patient. Now, in the case of a pediatric client, you're obviously not going to have much on the patient in the way of history other than maybe some birth information as far weight and type of birth and any complications. But their family history is very important to have so that you know if there is a history of cancer or hypertension or diabetes, so that as a pediatrician or a provider of care to children you could watch for that.

Number 15: allergy information. That's got to be prominent on the chart. Now, I've heard all sorts of different requirements coming out of state inspectors. Some want it on the inside, lower left-hand corner and in every chart they want to have allergy stamped on it or a big red sticker. Personally, I've not been able to find anything that stipulates where it has to be other than it has to be prominent on the chart. And from a malpractice perspective, you want it to be prominently displayed on the chart to protect you in any possible litigation proceedings that might come against you as a provider.

In my opinion, you shouldn't have a sticker on the chart unless they've got an allergy. It's kind of like the little boy that cried wolf. If every chart has a red sticker on it, it ends up meaning nothing so put those on the chart of patients that that have a drug allergy, writing in what they're allergic to. Make sure that it matches back to the medical history. Now, many times the patient will say they're allergic to something when they're not and that's where the provider has to figure that out and make note of it in the chart.

For example, a patient may say they're allergic to aspirin. Maybe in reality, they're not allergic to it. They just don't tolerate it well. It upsets their stomach. Perhaps that's the thing. But they consider that allergic. Well, the doctor maybe doesn't consider that an allergy. That's just an intolerance of a particular medication. So what it says in the medical history that the patient fills out sometimes may not match what is shown on the chart as far as their allergies to medications. If it doesn't match, then you want to make sure that there's documentation as to why it doesn't match. The provider must make that determination that that was an error on the part of the patient or that they really didn't understand the question.
No-shows are noted. This is a litigation issue. It's not a federal requirement to my knowledge that you have to have no-shows documented in the patient's chart and I get asked this question a lot. In my opinion, it's a good idea. The patient does have responsibility for their health care. Should you have a lawsuit placed against you for malpractice of any kind, it can be very helpful to be able to prove in court, either through no-shows noted in the chart or in a computer system by patient where you can print out the schedule of appointments they kept and the ones they didn't, where you can show, look, we made these appointments and they didn't show up. They didn't call and cancel. They just didn't make their appointment. That shows that you have done your part in establishing the appointment and that the patient failed to follow through. So those no-shows are important things to document in some way.

Now, one thing that's not on here, before the comment number 17, we should have MSP, Medicare secondary payer questionnaire. For the Medicare patient that form should be somewhere. If not in the medical chart, it needs to be in a separate file, but you should have that form. Technically, it depends on the FI how they interpret this, but my understanding is that technically the patient is supposed to sign something that indicates that Medicare is primary, that there's not someone else that's supposed to be paying for that particular office visit, on every appointment. Specific questions about MSP can be answered through your FI's Website, whether that be -- Trailblazer or Riverbend, Trispan or any of the other (many) FI companies handling RHC claims. In particular, I know that the Riverbend website has specific information, including the questions that are supposed to be asked, in their MSP section of their Website. This site is: www.riverbendgba.com.

Number 10: You need to include in part of the annual evaluation a review of the clinic's policies and procedures manual (PPM). This review must be done by the medical director, as well as the PA, NP, or certified nurse midwife, and the office manager. All these people should sign off on the annual evaluation report that results from all the areas we've been talking about so far. The purpose of this evaluation is to determine whether the utilization of services was appropriate and that you were actually following your policies and procedures and then any changes that need to be made in those policies.

Slide 12: we're talking about the staff considering those findings and taking corrective action if necessary. In other words, if you conduct an annual evaluation and say something like, "our policy and procedure manual needs to be changed on page 47, section whatever regarding medical records in that we no longer utilize a problem log or we have added the HIPAA security notice as one of the forms that must in the chart".

Well, that's fine for you to make that recommendation but if you don't actually follow through and do it by changing the policy manual, updating it, then it was pointless and that would be possible grounds for an inspector to say, wait a minute, now you're not only out of compliance with not having the form but you're out of compliance with your own recommendation from the annual report. You haven't done what you said you were going to do.

There are specific requirements as to who must be included in the group of clinic employees and governors that sign off on this annual evaluation and that needs to include someone who is not an employee of the clinic.

Slide number 15: A brief outline of what would be in the annual evaluation. I noticed earlier today, I made an error on this slide but it's OK. We're stressing, like in any good business, location, location, location, I guess. The overview of the rural health clinic: that would be analyzing your location, the scope of practice, the services you are providing. Just a simple paragraph that states here's what we're doing here. And then two and three: location, location; where are you located what counties do you serve, what's your market area.

Disclosure of ownership is important in that you need to be able to stipulate in this section that the clinic is still owned by the same entity, individuals, etc. as last year. And I apologize. I used the word midlevel and Mr. Finerfrock does not like me to use that word and I've got it in that slide. I really thought I took out all "midlevel" references to these medical professionals . Midlevel, meaning your nurse practitioner, your PA, or certified nurse midwife. So if I offended anyone with that, I do apologize.

Item number six on slide number 18: the definitions that you use in the report. This isn't a requirement but this is something that I use in my reports. This can be helpful especially for that person that is not a staff member that's going to review this report and sign off on it. You may be using acronyms that are unfamiliar to a non-medical person.

Now, that non-employee that you have on the Annual Review Committee could be the pharmacist in town or the pharmacist's spouse, your pastor, your pastor's spouse, etc. It can be difficult for them to understand all of the words in the report and it doesn't make sense to have them sign off on something they don't understand. So you might or might not want to use the definitions or have some sort of short glossary included.

Now it's time to review the encounters by type. That's the utilization report that we talked about earlier: Medicare, Medicaid, and all other. You can find out some fascinating information about your clinic by doing this on an annual basis. I have conducted Annual Evaluations for some of my clients for several years in a row, and its really fascinating to see how the patients types have shifted, especially if they had more than one location. It helps to go back and analyze why did we have a drop in our Medicare population visits during that year, why did we have such a dramatic increase in our Medicaid business during that year, and see what we were doing good and bad. Again, evaluating the total program. Taking a look at the whole picture and seeing where you're headed and where you've been.

Number eight: CPT coding analysis. It's not a requirement, but it certainly is a smart thing to do. This is an excellent report for analysis provided your software can generate the report. This is generally a "productivity report" by CPT code--by provider so that "Doctor X" report provides his or her visits by Medicare, Medicaid, and all other. You can combine data on physicians if you want or you can break them down by type and physician, but do it by CPT code.

For example, I have a lot of physicians that will tell me, I never, never, ever use 99211 in my clinic. Then when we run this report off the system, they've got 248 visits listed under 99211 and I ask them, "where did that come from?" They respond, "Well, I don't know. It must be my nurse using my number." Well, if that's true, they've got a bigger problem than was originally thought because if the nurse is entering information into the billing system under the medical provider's number, then most likely claims are being submitted under the assumption that the medical provider provided a service when in reality, the service was a "nursing service" only, and not billable as an encounter.

The E & M code 99211 is not a billable code for the rural health clinic. It is a nurse-only service and you don't know if it's being used until you run some kind of productivity analysis off of your system. So it's very important from a management perspective that you do this analysis, plus you're able to tell if you've got providers that are doing everything as a 213. If that's all they've got is a 99213 for 99% of their visits, oh, come on, you know, that's not realistic. You're not going to have all the visits at the 99213 level of service. That tells me that that provider is either being lazy or they just don't understand coding and they're just putting everything as a 213. The level of care provided and documented in the chart notes must justify the level that is billed.

All encounters simply cannot be the same level of service in a rural health clinic. You're going to have some 99214 and 99215 and a few 99212. Granted, 213 may be the most prominent code but it's not the only one. The only way you can find it out is to run that kind of an analysis. An annual evaluation is a good time to do it but it is not a requirement by the federal rules.

Number nine on slide number 19: cost analysis by category. This is a good time to look at the cost report and go back and look a little closer at it. I realize a lot of hospital-based programs don't share the cost report with the folks out in the trenches in the clinic, that it's a hospital administration issue and many times they don't even communicate to the providers or to the office manager anything to do with the cost report.

I believe that's a serious error on the part of the administration. The office manager and appropriate staff in the RHC should be involved in the cost report process especially in the area of collecting/verifying the numbers for the visits. It may be that the cost side of the cost report is not an area where the RHC manager even has access to the information, especially in a hospital-owned environment, but still, you need to confirm that the visit counts were correct, that they looked right compared to what the RHC manager knows it to be by being in the clinic every day, and then you can do an analysis of the cost to see how it fits with the overall operation of the clinic.

Number 10: is a statement of the scope of practice. Really, that fits into the overview section that we had earlier, just listing the services you provide, and any changes you may have made in the previous year.

Perhaps you've decided this rural health clinic's no longer going to provide x-ray services. X-Ray services are generally a money-losing service in a RHC. These cost of these services is not an allowable cost in the RHC cost report because it's a diagnostic test, so the RHC decides to get out of the x-ray business and just send them across the street to the hospital (or wherever). Well, you need to make a note in your annual evaluation that you have changed your scope of practice, in that you no longer provide x-ray services to your patients.

It also stands to reason that if you have changed your scope of practice by adding or deleting particular services, then your policies and procedures manual will have a change that year, reflecting the change in your services.

Number 11: the review of your policy and procedures manual. Some sort of report that indicates that a review was conducted by specific people and specific staff members and this non-staff person and here's what we found that we need to change and correct or update on it.

Number 12: on slide number 20, a listing of those on the review committee, their names and titles. Then signatures of that review committee; every one of them signing off on that evaluation report.

Item 14, Slide 21: recommendations for changes and improvement. In other words, we recommend that we do "blank". An example would be: you discovered during a walk-through of the clinic that there were no evacuation plans posted. Well, the reason for that was they repainted the walls two months ago and somebody just forgot to put them back up.

I admit, those evacuation plans are one of the dumbest things that's required. Who's going to stop and look at a burning piece of paper on the wall if the building's on fire. You're going to go out the nearest door. But you must have the evacuation plan posted. So that might be something that you would have in this section. Or maybe you haven't had a fire marshal's inspection in three years and you discover that as part of this annual review. Then your recommendation would be to get the fire marshal in and conduct the inspection that's required to be done on an annual basis.

Number 15: a timeline. In other words, you're saying that all these recommendations are going to be completed by a certain specific date so that you can then (on item 16, slide 22), you confirm those changes have been made and the medical director then signs off on this annual evaluation report.

Operator:

Jim Estes:

The annual evaluation is a great opportunity to conduct an inspection of your clinic. Now, is this a requirement of the annual evaluation report? I've not found any regulation or memorandum that requires a facility inspection by the clinic staff, but, boy, it sure is a good time to do it. You can get so busy in your rural health clinic with the daily operation of just getting the bills paid, getting the patients taken care of that you overlook important facility and safety issues.

I've talked to a lot of folks who said "we could get so much done around here if it wasn't for these cotton-picking patients coming in all the time". Well, of course, without them you wouldn't be in business and we know that. But by the same token, it can be very, very hectic in that clinic. As a result, you tend to forget things. Things get missed. An inspection similar to what the state inspector will do of the facility, not just the policy manual and the charts, but actually going through the building and looking at the things that they look at is very valuable and often reveals problems that you don't even know exist.

Here's an example of what I mean. One of my clients had me conduct their third consecutive annual evaluation. They had hired a new provider and this provider just insisted on being able to do a certain thing that really no one else knew she was doing. She was keeping a stainless steel container underneath the sink (with no locks on it). That container had detergent -- cleansing material in it -- liquid -- along with the speculums that she would use during the day, that she would just toss in there to soak.. And next to it was the powdered detergent cleaner, disinfectant that was next to it. There was no lock on the cabinet. Any kid could get into it quickly. Besides that, that's not the place to put used speculums. Not under the sink in the exam room.

The office manager had no idea this was happening until I came in and did the walkthrough and I took her by the hand said what is this. And she had a fit. Well, you know, these things happen. More typical is the staff not keeping a log of medicine samples given to patients, if that's required by your state regulations that you log your samples in and out. Or, perhaps the nurses are not dating and initialing those multiuse vials or those clini-sticks for the UAs; those types of things that need to be dated when you first open them. Perhaps that's not happening.

Perhaps you've got outdated supplies or drugs in the building. Maybe your crash box that you have for your emergency response, which is a requirement of the Rural Health Clinic. Maybe the drugs in there are two years old and nobody ever bothered to look. Well, you can't have outdated (Epi) and (Beni) and anticonvulsants and old, brittle airways. Perhaps your oxygen tank's empty. Sometimes you don't see this unless you stop and walk through the building and do it like a state inspector would do. That can reveal a lot of extra areas that you might want to look at closer and can in fact become part of your QA program.

Now, real quickly -- I see I've got two minutes left before we go to questions -- this report -- this annual evaluation process is a requirement for this year for 2005. It sounds like it's going to be a requirement for '06. The best we can tell about the final regulations from the Balanced Budget Act of '97 that they're rescinding and reprinting is that it will not take affect until sometime in '06 on the new regs where we get the QAPI requirement coming in, which will do away with the actual annual evaluation report. Not all the components but the report itself.

For now, if you're rural health clinic in 2005 and it looks like any portion of 2006 is your fiscal year, you will have to do the annual evaluation report for this year and for '06. Then you can stop and delve into the QA PI mess that will be coming our way eventually.

With that, I come to my last slide that says questions before the thank-you slide.

And Mr. Finerfrock, I think we've got maybe 30 seconds before question time anyway so it looks like we're about there.

Bill Finerfrock:

At this time, what we would like to do is we will open the phone lines for questions. The Operator -- I'll turn it over to the Operator and she will let you know how you can ask a question. So Operator, if you would give the instructions on how to ask a question and when you -- when your line is opened up, if you would give us your name and also where you're calling from.

Operator:

Sue Morris:

Jim Estes:

Sue Morris:

Operator:

(Mike Shumaker):

Jim, (Mike Shumaker), Park City …

Jim Estes:

(Mike Shumaker):

... Park City, Kansas.

Jim Estes:

(Mike Shumaker):

Hey, Jim, on the signatures for the physicians, I've got a program memorandum from Department of Health and Human Services dated March 28th, 2003. What it states is in regards to the signature, ((inaudible)) may include written signatures, initials, computer (fee), or other code.

Jim Estes:

(Mike Shumaker):

On the progress note, on the (soap) note.

Jim Estes:

(Mike Shumaker):

Well ...

Jim Estes:

(Mike Shumaker):

... well, actually, I talked to Bill about this a couple of years ago because we had some issues with Riverbend in regards to this and it is our understanding that on the dictation the patient or the physician's name is typed out completely, for instance, R.W. Yoakum, and it is our understanding with this memorandum, he can initial that.

Jim Estes:

(Mike Shumaker):

OK, that memorandum is March 28 of 2003.

Jim Estes:

Bill Finerfrock:

(Mike Shumaker):

Let's see, it's CMS publication 60A. I don't know if that'll help you or not.

Bill Finerfrock:

(Mike Shumaker):

60A. The transmittal, would that help you at all?

Jim Estes:

(Mike Shumaker):

A03021.

Bill Finerfrock:

Jim Estes:

(Mike Shumaker):

Thank you.

Bill Finerfrock:

Jim Estes:

We'll confirm it.
NOTE FROM JIM:
Following the session I contacted Cindy Geren with Riverbend with the following e-mail.

Here's a copy of that e-mail and her response:
JUNE 14, 2005

Cindy:

The memorandum in question is Change Request 2511, Transmittal A-03-021.
Among other things it has a section: "RHC/FQHC Guidelines for Signature and
Documentation of Medical Records" on the next to last page.

Specifically this says "...the identification may include written
signatures, initials, computer key or other code" in reference to
authentication in a method established to identify the author.

What I'm getting out of all this (besides a headache!) is that as long as
the clinic has a signature/initial verification page in their policy and
procedure manual that clearly established authentication of the
signature/initials of the medical provider, then perhaps initials on
dictated and other medical chart entries would work?

The last paragraph of this memorandum says "For example, stamped signature
need not be countersigned or initialed by the provider. This would negate
the expediency of using a stamped signature. Neither should unsigned
dictations be accepted as an acceptable practice"

So, now I'm really confused. I'm still gonna teach "sign the dictation, notes, etc.", but I do see where folks can get the idea that a
stamped signature is alright, provided you have the appropriate policies in
place, and that initials are acceptable, provided you again, have the
verification/authentication policies and pages in place.

What Say YE??? Jim
Jim - After digesting all the info we have, including the CR you quoted
below.....I see no changes to what Dr Duval published in the LMRP for RHC.
The paragraph you quoted from the CR pertains to electronic medical records.
We also have that noted in the LMRP. I agree with you.....SIGN the records.

Cindy

Now, back to the questions and answers:

Louise Rumor:

Hi. My name's Louise Rumor. I'm from the Village Clinic in Chiloquin, Oregon. We're a new rural health clinic. We received our certification in November of 2004. When -- at what point am I required to do this annual evaluation?

Jim Estes:

Now, you don't have to do it all at one time.

Louise Rumor:

Right.

Jim Estes:

Louise Rumor:

Thank you.

(Steve):

Hi. This is (Steve) from Michigan and I wondered whether it would be possible to get this presentation on some sort of recording that we could then work with our other rural health clinics to listen to and watch your wonderful presentation online.

Bill Finerfrock:

What we will do is make a transcript of the call available and this is all being transcribed and we will then, once we get the transcription, get that to Jim, have him go through it to make sure that it accurately reflects what was said, and then that will be posted on the NARHC Website as well as the ORHP Website and individuals can download the transcript.

This series, as I mentioned, is being funded by the Office of Rural Health Policy. There will be -- hopefully this will be continued next year through the funding process. Certainly looking at recording or perhaps building that into the budget but at this time there's not money in the budget to pay for this call to be recorded and kept online.

(Steve):

That makes -- that makes great sense. So we could download it and burn it to a CD and share that CD with our rural health centers and let them go to your site and read that and watch on the Internet?

Bill Finerfrock:

(Steve):

I just mean the PowerPoint that we just all watched. I was sitting here going along clicking on PowerPoint and going through a slide.

Bill Finerfrock:

(Steve):

Good.

Bill Finerfrock:

(Steve):

OK, so the PowerPoint will exist and you'll send a CD out with his comments and then we could -- we could ...

Bill Finerfrock:

(Steve):

OK.

Bill Finerfrock:

(Steve):

OK. All right. I can -- OK, I got it. Thanks.

Operator:

Tom Martin:

Jim Estes:

It is important that they not be on the staff of the clinic; staff who's cost is in the RHC cost report, if you follow me. If they're not a staff person that's paid through the cost center of the rural health clinic, I believe you should be OK there. If you mean an employee of the "mother" corporation, you know, you're talking marginal and it's going to be up to the interpretation of the individual state inspector as to whether or not that will fulfill the non-staff person requirement because there can be a huge corporation that owns the hospital who may be Columbia or Tenant and it's someone from another city that happens to be there and they utilize them as the non-staff person, they have no contact with the clinic, they have no inherent interest in the clinic, there's no conflict of interest in any way, they're not paid out of that clinic's cost center, I don't see why a state inspector would have an issue with that.

Tom Martin:

Jim Estes:

Tom Martin:

Operator:

(Mary):

Yes, this is (Mary) from Iowa and I have a question on the policy and procedure book. We have a lot of our policies online so that we view them, you know, online. We can print but would we have to print to make an actual manual?

Jim Estes:

(Mary):

Right.

Jim Estes:

(Mary):

I guess not.

Jim Estes:

(Mary):

Right.

Jim Estes:

(Mary):

OK, and then a comment on the MSP. We do have ours online. It worked great.

Jim Estes:

(Mary):

Yes.

Jim Estes:

(Mary):

Right.

Jim Estes:

(Mary):

Right.

Jim Estes:

(Mary):

Thank you.

Bill Finerfrock:

One is from (Louise Levholt) who asks: we're looking at electronic medical records. What type of requirements will there be for the chart audit to comply with rural health? We want to go paperless.

Jim Estes:

I would say, depending on the clinic's encounter volume, it would make a difference as to how many number-wise you're looking at. I do the same thing with EMR, in that I randomly select certain charts and go in to make sure that forms are present even if it's a scanned document. Many times a consent, release and that type of form is a scanned document. It's not actually part of the database. They fill the form out, scan it into the system, and there it is. Granted, the patient notes are typically electronic but a lot of the other things can be scanned documents. So I don't see any difference between EMR and a paper chart as far as what you look for in a chart audit.

It could be easier with EMR because there are some things, depending on what system you've got, that the doctor or the provider can't close that note until they finish that note and it won't let them close until everything's done that needs to be done. So there can be a great advantage there from an audit perspective if you've got EMR. Many auditors will go a lot faster along that part of the process during the inspection.

Bill Finerfrock:

Operator:

(Jody):

This is (Jody) from Iowa. My question was already answered regarding the consent form. Thank you.

Operator:

Harold Curtis:

This is Harold Curtis from the state of California. I had two questions.

One was: there was a Website that was given at the beginning of the presentation which I only got part of. I was wondering if I could have that again. And the second question was dealing with the rural clinics. How much leeway are they going to have with the evaluation when it's quite possible that a lot of them may not have the infrastructure in place to carry this out completely?

Jim Estes:

Harold Curtis:

Exactly.

Jim Estes:

My understanding is it's a requirement in certification, so technically, they could say you're no longer a rural health clinic because you didn't do it. I've never heard of that happening. Most -- 99 percent of the state inspectors that I've dealt with, and I've got clients in 45 states -- 99 percent of them are not there to put you out of business or to shut you down. They are there to make sure you're in compliance with federal and state regulations. And many times before they leave, they'll say, you know, if you'll do this right now, we won't even have to write a citation and make you correct it. If you'll correct it with me standing here, we'll consider it a done deal. I mean, that's just how cooperative most of them are.

Now you get the rare occasion when they get a burr under their saddle, as we say in Oklahoma, and they'll ride it until the horse dies. I mean, they can just get really upset about what would seem to be insignificant things. Obviously, if you haven't done the report, you can't go back three years ago and do it because it's time-sensitive. You're looking at it now-"real time". It is a snapshot: evaluating your program today for this time period. You could go back and reconstruct some of it but, I mean, how can you evaluate your policy manual from three years ago and see about any changes. It's not -- you're not back three years ago. You can't go back in time.

So my comment would be do it, do it now, assign someone to do it, hire somebody to do it, but get it done. It really shouldn't be that big a deal as far as the infrastructure and ability of someone to take that on and do it. It's a project that should take a portion of a week of someone's time if they're going to devote part-time to it; otherwise, you're talking about a day that they ought to be able to get this completed.

Bill Finerfrock:

So Jim, if individuals have questions that they would like to submit, would you be willing to respond to questions people could submit to you directly?

Jim Estes:

Jim Estes:

Bill Finerfrock:

As I mentioned earlier, this series is sponsored by the Office of Rural Health Policy in conjunction with the National Association of Rural Health Clinics. This is the third in the series. We are planning six calls. The next one will be in about six weeks and I'm hopeful that it will be on cost reporting issues for rural health clinics. We will get information out on that as those details become more firm. Any comments that you'd like to submit with regard to this series, please send an e-mail to info@narhc.org.

We appreciate everyone's participation today. We hope you found it very helpful. And again, thank you to Jim Estes for giving of your time and expertise in assisting folk with today's program.
We look forward to your participation in the future and we will be in contact with you. Thank you.

Operator:

END