Operator:
Good day and welcome to
this RHC Technical Assistance conference call. As a reminder, this
conference is being recorded.
At this time, I would like to turn the conference
over to Mr. Bill Finerfrock. Please go ahead, sir.
Bill Finerfrock:
Thank you, operator. I
want to welcome all the callers, participants of today's presentation
to Rural Health Clinic rules update.
My name is Bill Finerfrock. I'm the Executive
Director of the National Association of Rural Health Clinics. In
addition to being your moderator, I'll also be the presenter for
today's program.
Today's program is scheduled for one hour. The
first 45 minutes will consist of my presentation and we'll do about
15 minutes dedicated to questions and answers you may have with
regard to the rules.
This series is sponsored by the Health Resources
and Services Administrations, Federal Office of Rural Health Policy
in conjunction with the National Association of Rural Health Clinics.
The purpose of this technical assistance series
is to provide RHC staff with technical assistance and RHC-specific
information. Today's call is the 13th in the series which began
in 2004.
A transcript of all of the previous calls is
available on the ORHP Web site in addition to the slides for the
previous calls. There is, as you know, no charge to participate
in this series. Individuals can sign up to receive announcements
regarding call dates, topics, and presentations. And that Web site
address is www.ruralhealth.hrsa.gov/rhc.
During the question and answer segment of today's
call, we ask that you identify yourself by name location, and the
state that you're calling from.
I also want to remind callers that there will
be a link to today's presentation as well as the transcript of the
call.
What we'd like to do today is talk about the
RHC rules situation. For those of you who may be new to the program,
I'd like to start out with a little bit of history.
In 1997, Congress enacted a number of changes
in the Rural Health Clinic's law that required the Department of
Health and Human Services to publish new rules for the RHC program.
Those rules were published in February of 2000 as proposed rules.
The public had an opportunity to comment on those
proposed rules during a 60-day public comment period at which time
the public comment period was closed and the agency went back and
reviewed all those public comments.
On December 24, 2003, the Centers for Medicare
and Medicaid Services published in the Federal Register new final
rules adopting, making changes to the RHC program as part of that
rulemaking process.
However in publishing those rules on December
24, 2003, the agency violated a change in the federal law that had
been enacted in the time period between the publication of the proposed
rule and the publication of the final rule which stipulated that
Centers for Medicare and Medicaid Services could not publish a final
rule three years after the publication of a proposed rule.
Because the proposed rule was issued in February
of 2000 that meant that the department had to issue the final rule
by February of 2003. By issuing the rule in December of 2003 they
violated that statutory requirement.
That necessitated the agencies suspending any
enforcement action on those rule changes. And that was done in a
letter to state survey and certification agencies and others involved
in the RHC program informing them that although those rule changes
appeared on the books no enforcement action or any other action
was to occur as a result of those changes. They were, in effect,
suspended.
That suspension order, however, is not an official
removal or withdrawal of those rules. And so they continue to exist
on the books. And it was necessary for CMS to formally withdraw
those rules.
On September 22nd of this year, just about a
month ago, CMS formally issued a notice withdrawing those rules,
the December 24th rules changes, that had been published in 2003.
It was issued as what is referred to as an interim final rule.
The words - the inclusion of the word interim
is, in a lot of ways, irrelevant and sometimes confusing to those
of us who simply have to understand what's going on. The reality
is it is a final rule which means that those rules are effectively
wiped off the books, those rule changes are wiped off the books,
and we revert back formally to the rules that existed prior to the
publication of new rules in December of 2003.
Now what does that all mean to you? As a practical
matter it means nothing because the program continues to exist today
as it did in August of this year, as it did in June of this year,
as it did last year, the year before, and the year before that.
Essentially nothing has changed in the RHC program
from what you have been doing and what your expectations and anticipation
has been with regard to any of the program requirements. All the
program requirements you've been operating under continue to be
in existence.
In publishing that notice, CMS also let the community
know that it is their intention to issue new proposed rules at some
point in the not-too-distant future at which time the public will
have another opportunity to comment on those proposed rules and
CMS will once again seek to make rule changes to the RHC program
in order to be in compliance with the statutory changes made in
1997.
At this time, we do not know exactly when those
new proposed rules will be issued. Our expectation is that it will
be some time after the first of the year. We also don't know officially
or formally what will be in that proposed rule although we anticipate
that a significant part of the new proposed rule will be the language
that was in the proposed rule that they have just suspended.
In other words, CMS will now try to adopt those
rules in a way that would be in compliance with the statutory requirements
for the agency.
So one of the things that we want to do today
is go over what some of those anticipated changes are because there
are many clinics that are new to the programs since this whole process
started. There are new staff. There are a lot of folks who may not
even be aware of the potential changes that may be coming down in
the not-too-distant future.
Because this is only an hour-long call we're
not going to be able to go into great detail on all the provisions,
what the implications may be and what clinics may or may not be
able to do to prepare themselves.
I would encourage you to consider attending one
of the Rural Health Clinics meetings that we put on or that others
put on. We will be having our annual meeting here in Washington,
D.C., in November, November 16th, 17th, and 18th, where we will
have a very exhaustive and extensive discussion about these rules.
We will have representatives from the Centers
for Medicare and Medicaid Services in attendance who can talk about
these rule changes and what it is that they're thinking of doing
as this program moves forward.
There are - even though these rules have, however,
been suspended and now withdrawn, there are some things that did
not change that were adopted as part of either the '97 statute or
earlier statutory changes to the RHC program that folks also need
to be aware of. And we'll go over those today as well.
But one of the key messages I want you to go
away with today is that essentially nothing has changed with regard
to how you operate your Rural Health Clinic, the rules under which
you operate, et cetera.
You are not in any danger of decertification
in the near term. You will not be cited for violations of something
that were in those rules that have now been suspended.
As I said, this all started most recently on
September 22, 2006 when CMS announced the withdrawal. This was done,
as I said, because of the violation of the statute that requires
them to issue a final rule within three years of the issuance of
a proposed rule. And it simply restores the status quo.
Now there are a couple other provisions that
continue to be in effect that I did want to bring to your attention.
There is a provision that requires that Rural Health Clinics have
to have a certain staffing requirement.
And there's been some confusion on this because
of the wording that was in the interim rule. The staffing requirement
that you all have operated under with regard to physician assistants
and nurse practitioners is a 50 percent requirement.
Fifty percent - you must have a physician assistant,
nurse practitioner, certified nurse midwife on-site and available
to provide care 50 percent of the time that the clinic is open.
In reading the interim final rule what it says
is that they are restoring the old requirement that said 60 percent.
And you will see that actually in writing in the rule. Unfortunately
although it says that, that is not actually what is happening.
The 50 percent requirement remains in effect.
The 60 percent requirement is in the regulation but it is no longer
reflective of what the law requires, which is 50 percent. I apologize
to you if that's confusing but the status is that you are at a 50
percent requirement. You are not at a 60 percent requirement.
There has also been some confusion with regard
to the QAPI requirements, the quality assurance program improvement
initiatives. Now, I'm still seeking some clarification on this.
QAPI had not been before and is not now a mandatory requirement.
It is a voluntary program. My understanding is
that if you wish to participate and undertake a quality assurance
program improvement initiative you can and that that would be evaluated
by your surveyors as part of your recertification. But we are seeking
clarification on that.
One of the other questions that has come up is
with regard to commingling and whether or not the commingling requirements
are now null and void. Commingling has never been a permissible
activity. What was published was an attempt by CMS to clarify what
constitutes commingling.
And that remains impermissible as far as the
clinics are concerned. You cannot commingle your RHC with a non-RHC
services on a simultaneous basis. So I just - I wanted to bring
those out as separate issues.
In terms of decertification, under the rules
that have now been withdrawn, there was a process by which the secretary
could move to decertify clinics that were no longer in a rural area
or no longer in an underserved area unless the clinic could demonstrate
that they continued to be essential to the availability of care
in their community.
And there are a variety of ways in which clinics
could demonstrate and apply for a waiver of that decertification
process. That decertification process goes away. There is no mechanism
under the rules for decertifying a Rural Health Clinic.
That issue will have to be addressed under the
new proposed rules along with a process for allowing clinics to
demonstrate that they continue to be essential. Same thing with
clinics that are no longer in rural areas. There is no process for
decertifying clinics that are no longer in rural areas as well.
So until the new rulemaking starts and is completed
you are not in jeopardy of losing your RHC certification because
you are no longer in a rural area or no longer in an underserved
area.
At some point, that may become an issue. But
at the current time it is not. Along with that - you are not in
jeopardy of losing your RHC designation because your shortage area
is out of date.
There is a requirement that your shortage area
cannot be more than three years old. They will not be able to decertify
you because you have a shortage area that is out of date. Again,
at some point they may. But at this time they do not.
That provision, the timeliness of your shortage
area is, however, applicable to new Rural Health Clinics. If a facility
wants to be designated as an RHC they must be able to demonstrate
that the shortage area designation that they're using for that clinic
is less than three years old.
So that standard is applied to clinics that want
to enter the program but it does not apply to clinics that are already
in the program. It may at some point but it does not at this time.
In terms of long-term actions, as I mentioned
earlier, what changes can we expect?
I believe that there will be additional issues
beyond what was in those final rules that will be incorporated into
the new proposed rule as well. So it will not simply be a reiteration
or re-publication of what's been drawn. But there will be new issues
that are brought forward to the RHC community for comment.
Again, I don't anticipate that occurring until
after the first of the year. Once that's published we will make
that available to the RHC community. Typically when a rule is published
there are 60 days for the public to comment on that at which point
the comment period closes, the agency reviews their comments, and
then publishes final rules.
So at this point that is the best guess that
I can provide you as to when we anticipate or what may happen.
So what was in that rule? What I'd like to do
now is go through some of the things that were in the rules that
have been suspended and because we do anticipate these issues coming
forward again. And I think it's important that you be aware of it
and potentially be prepared to deal with these changes if and when
they come about.
I've already talked about a few of these briefly.
The new rules will stipulate that all Rural Health Clinics must
be located in an area currently designated as a shortage area. Currently,
as I said, means that the shortage area designation cannot be more
than three years old.
So for example, we are here in 2006. If the clinic
were to contact a state agency and say, "I'm interested in
becoming a Rural Health Clinic," and they said what is your
date of designation for the health professional shortage area, medically
underserved area, or governor's designation that you're looking
to use for purposes of RHC.
They would look to see whether or not that was
approved or was updated since 2003. So if during 2003 or later,
that shortage area designation had been updated and verified as
still valid the clinic could use that shortage area designation
for becoming an RHC.
If the shortage area designation was done before
2003 then it would not be considered a valid shortage area designation
because it didn't meet the current criteria and therefore they could
not proceed ahead with the application until such time as that shortage
area designation was brought up to date.
The rule that has been withdrawn established
a mechanism for RHCs that can no longer meet the location requirements
to apply for an exception to this requirement and continue to participate
in the RHC program.
This was a mechanism that, as I mentioned earlier,
was required by law and stipulates that if you're a Rural Health
Clinic that has lost its shortage area designation or its rural
designation, the Secretary of HHS has to afford you an opportunity
to appeal that determination and demonstrate to the Secretary that
you continue to be essential to your community.
The rule laid out some very specific ways in
which clinics could demonstrate that they were essential to their
community and a timetable under which those considerations for exemption
were to unfold.
And those can all be found in those rules. And
I would encourage you to take a look at those criteria. If you feel
that you are at all in jeopardy of losing your shortage area designation
to see what kinds of things you might able to do in order to be
able to retain your Rural Health Clinic designation.
The rule also limited the staffing waiver for
the PA, nurse practitioner, certified midwife staffing requirement.
I mentioned earlier that you must be able to demonstrate that you
have a PA, NP, CNM at least 50 percent of the time that the clinic
is open.
One of the issues that has come up over the years
is what happens when a clinic loses their physician assistant or
nurse practitioner, how long do they have to replace that individual?
Typically you're given initially 90 days to replace your PA, your
nurse practitioner or nurse midwife.
If at the end of 90 days you haven't found a
replacement, you would have been subject to citation for a deficiency
and potential decertification as an RHC.
However the law was changed several years ago
to establish a waiver process by which clinics that were having
difficulty finding a replacement could seek a one year waiver of
the RHC staffing requirement.
The law was subsequently modified in 1997 to
stipulate that that waiver could only be used by clinics that are
already in the program. What that means is that when you initially
are certified as a Rural Health Clinic you must demonstrate that
you can meet the staffing requirement.
You cannot submit a waiver request concurrent
with your application to be a Rural Health Clinic. Up until then
clinics seeking certification could come in and apply for a waiver
at the same time they were applying to be a Rural Health Clinic.
What the law says now is once you're a Rural
Health Clinic and you've been certified and you lose your PA, your
nurse practitioner, or your nurse midwife, you can then apply for
a waiver. But you at least must meet that staffing requirement at
the time of initial certification.
That was referenced in the rule. That part of
the rule has been withdrawn. But the law remains on the books and
so CMS is still bound by the law which means that you still cannot
apply for a waiver at the time of initial certification as an RHC.
So even though it has been withdrawn and you
see that in the rule it doesn't mean that that requirement goes
away.
The rule also codified the definition of a bed
for purposes of the RHC cap exception for hospitals with fewer than
50 beds. The key word here is codify. Again, that was done. The
underlying change there was done by the statute by the underlying
RHC law.
And therefore the change in the regulation was
merely a ministerial function to put the language of the regulation
to make that consistent with the language of the law. The fact that
the regulation now has been withdrawn and that language cannot be
found in the regulation does not mean that it goes away because
you still have the underlying law.
I like to explain this to people when there's
a conflict between the law and the regulation and an interpretation.
Many of you may remember the game we played as kids called Scissors,
Paper, Rock where whatever you put out something else might trump
that.
In that game paper always trumped rock. And in
our regulatory/statutory world if you think of the regulation as
the rock and the statute as the paper the statute always trumps
the regulation.
So it doesn't matter what the regulation says.
If the statute is clear, and in this case the statute is clear,
just as in the case of the waiver it is clear and the staffing requirement,
the 50 percent staffing requirement, the statute is clear. So it
does not require regulation in order to make that language effective.
The law itself is clear enough. So the law remains in effect.
The rule also clarifies Medicare policy, as I
mentioned earlier, as it relates to commingling. And I think the
important word here is clarify. It does not - by the withdrawal
of the rule and withdrawal of the clarification - it does not mean
that commingling is now permissible.
It simply means that the language that was there before saying that
commingling is inappropriate remains. However that language is not
as clear as it could be.
If you have any questions about whether or not
your activities constitute commingling I would encourage you to
contact your state survey and certification agency or your fiscal
intermediary to get that clarified or to get some assistance.
You can also contact us and we can try and provide
you with some guidance if you have questions. And my e-mail is,
for those of you who may not know it, is info@narhc.org.
I mentioned earlier that it also codified the
PA, NP, CNM staffing requirement. And that continues to remain in
effect. It restricted the staffing waiver. And the rule mandated
the establishment of a quality assessment performance improvement
initiative. That QAPI initiative goes away. There is nothing in
the rules now with regard to QAPI.
I do believe, and I'm trying to get clarification,
that you can voluntarily do a QAPI.
I do want to talk a little bit about some of
these points because there is some confusion. On the issue of commingling
I think one of the key things there is to understand that commingling
refers to the simultaneous operation as an RHC of a traditional
fee for service Medicare practice.
And it's important that we understand that this
is all in the context of Medicare. This does not speak to what you're
doing with commercial, how you're paid by commercial insurers. It
doesn't speak to how you are paid by Medicaid.
This only applies to the internal operations
of your clinic as it relates to the care of Medicare patients. And
what it says is you cannot simultaneously provide "fee for
service" services to Medicare patients within the four walls
of the RHC at the same time that you are providing RHC services
to Medicare patients by the same personnel.
So, for example, we have a rural health clinic
whose posted hours are 9am to 6pm Monday through Friday. During
RHC hours of operation, a physician goes go into exam room one and
see Mrs. Jones, a Medicare patient, and says, "Thanks for coming
in and I appreciate it and he does the evaluation, does the diagnosis,
does whatever the physician deems appropriate for that patient,
and signs the chart. The patient is released and goes out and the
physician says, "We're going to bill you for this visit as
a Rural Health Clinic visit." Well it has to be billed as an
RHC visit because the services provided were RHC services and it
occurred within the four walls of the RHC.
Now the physician then immediately enters the
second exam room with a different Medicare patient, Mrs. Smith.
This is still occurring during RHC Hours. Mrs. Smith is in need
of a procedure and the physician says, "I'm going to perform
the procedure while you're here today, Mrs. Smith," and then
turn around and bill that procedure under Medicare Part B.
Effectively that physician is simultaneously
providing Part B services and Rural Health Clinic services, and
that is not permissible.
What they're primarily concerned about is really
what amounts to double billing. In those instances the practice
is effectively double billing Medicare for that second patient during
that procedure because they're getting all the physicians costs,
overhead, salary as part of their RHC because it's occurring in
the four walls during RHC hours but then they're turning around
and billing Medicare Part B for services provided by that same physician
during RHC hours in RHC space. And that constitutes double billing.
There's some further explanation of commingling
that are in the slides that you were sent. And you can read through
those and see what some of the additional criteria are.
I do want to point out that there was an exception
to the commingling requirement. And that had to do with situations
where there was a critical access hospital or a rural hospital where
the rule did allow for the sharing of staff in those situations
out of recognition that where you have a critical access hospital/Rural
Health Clinic there may be a severe shortage of staff and the necessity
to share staff. And therefore that was permissible as long as you
maintained an effective tracking and cost allocation process in
those situations.
Again, this is one of those situations that's
not clear what happens to this provision with regard to the withdrawal
of the rule and we are seeking clarification on that.
Next I just wanted to touch briefly on the hospital
bed definition. This is really going to be very brief. But for those
of you who have Rural Health Clinics that are owned and operated
by hospitals with fewer than 50 beds I think it's important for
you to understand how beds are counted for purposes of the program.
And this provides you with the citation and reference
for how you are to count a bed. One of the key components is that
it is a bed that is available. So it does not look at what are your
licensed beds. You may be a hospital that's licensed for 60 beds
but you are effectively only making 45 beds available because of
staffing, demand, whatever the reason.
So even though you may be a 60, a licensed 60-bed
hospital, if you only make 45 beds available then you can come in
under the 50-bed exception and seek and obtain a waiver of the RHC
cap.
So it's important for you to understand how beds
are counted. It may make a difference for you as to whether or not
your hospital qualifies for the exception or it doesn't.
The RHC certification/recertification criteria
are also laid out briefly in the slides that you should have received.
And it goes through some of the highlights of those which I've already
touched on in terms of the shortage area, et cetera.
I do want to highlight some of the criteria.
And I encourage you to go back and review these in greater detail
and again if you have questions. There are essentially four ways
in which a facility would be able to qualify for an exception and
that is if you are considered to be the sole community provider,
i.e., you're the only primary care provider in your service area;
you are the majority community provider, which means that you are
providing the lion's share of the care to the Medicare, Medicaid,
and uninsured populations in your community, and there are different
ways in which those numbers are calculated; you operate a specialty
clinic, and there are specific specialty services that if you are
providing certain services, mental health, OB-GYN, some others,
that you would be considered to be a specialty clinic; and then
if you're in an extremely rural community and there are definitions
of what it means to be extremely rural that you could apply for.
And again I would encourage you to review some
of those criteria to see whether or not you might be able to comply.
I want to jump ahead to the application of the
Part B co-pay and deductible, the revised - the regulations sought
to clarify how a Rural Health Clinic must apply the deductible in
coinsurance rules for a Medicare beneficiary. It pointed out that
the deductible is the same.
The RHC will pay - or the patient pays RHC charges
up to the unmet annual deductible. And then it clarifies that Medicare
pays 80 percent of the RHC all inclusive rate. The patient is responsible
for coinsurance equal to 20 percent of the charges for the encounter.
Now again even though this is a provision that
is in the rules this is what is considered a clarification of the
RHC rules. Therefore the withdrawal of the rule does not negate
any of these. And I don't think that should come as a surprise.
One of the things that's in the rules was a reflection
of the fact that there is now the imposition, it has been since
1997, a cap on all Rural Health Clinics payments, the per-visit
payment, except for those RHCs that are owned and operated by a
hospital with fewer than 50 beds.
Again, this is laid out in the rules. Even though
the rules are withdrawn the exception still exists for hospitals
with fewer than 50 beds. And the cap continues to apply to all other
RHCs and again because the statute is clear on this particular point
the withdrawal of the rule does not overturn the underlying law.
And the underlying law continues to be operational.
Again, in your slides there are definitions of
beds and also there is a special exception definition for hospitals
that can have an alternative definition of 50 beds if you are sole
community hospital, you are located in a level eight or level nine
non-metropolitan area, and you have an average daily census that
does not exceed 40.
It's a fairly narrowly construed alternative
definition that was put into the rules.
The QAPI program is something that I would encourage
all of you to take a look at the slides and try to become more familiar,
attend some programs. We will be doing programs and initiatives
on how to establish a QAPI.
If you go to the ORHP Web site that was referenced
earlier in the presentation you will see some presentations that
were done, how clinics had set up a quality assurance program improvement
initiative, and information that you can download that might give
you some ideas on how to do a QAPI initiative.
As I mentioned this is not a mandatory program.
However, we do anticipate that at some point this will become a
mandatory program and would encourage you to give some thought to
look at this particular initiative and see whether or not there
are some things you might already be able to start to do to allow
you to be in compliance with the QAPI program once it does go into
effect.
Those are really the highlights of what is in
the rule and what is - or the rule that has been suspended. I don't
think I can say strongly enough that folks should not be getting
upset. They shouldn't be concerned. Essentially nothing has changed
in the way that you operate your RHC today compared to where you
were a year ago, six months ago, three years, et cetera.
The action was taken on the 22nd of September
was a ministerial action. It was necessary in order to allow the
program to move forward. To get the rules clarified they had to
go through this process.
But despite the fact that the language may look
like there have been significant changes and in particular things
like I said, the staffing requirement, the amount of staffing, the
waivers, some of the other provisions, essentially the rules are
unchanged from what you have been complying with since you got into
this program.
I'm ending a little bit early in terms of my
formal presentation. But at this point I'd like to open it up to
any questions that you may have for clarification on the rule or
anything else that I might be able to assist you with.
Operator, if we can start to open the lines up
for questions. I'd just like to remind the callers that when your
line is opened up if you would please identify yourself by name
and your location, not necessarily the city but the state that you're
calling from, it would be helpful. Operator?
Operator:
Thank you. The question
and answer session will be conducted electronically. To ask your
question, please press star one on your telephone keypad at this
time. A voice prompt on your phone line will indicate when your
line is open. And once again, please state your name and city and
state when you pose your question. Once again, star one at this
time.
And we'll take our first question now.
(Mary Peterson):
Hi. (Mary Peterson, Miles
Bluff Clinic in Wisconsin.
Bill Finerfrock:
Hey, Mary.
(Mary Peterson):
The - what we are wondering
about is the, you know, within 30 miles, Rural Health - another
facility within 30 miles.
Bill Finerfrock:
Right.
(Mary Peterson):
Let's say there are other
facilities, you know, multiple Rural Health Clinics within whatever
radius, 30 or more miles, 30 or less miles. Who is the decider of
which of those would survive that scrutiny if that's in the final
rule?
Bill Finerfrock:
Right. I think that's
a good question. I think that probably what you would look at is
that are there other criteria that you could demonstrate. I think
each of these criteria exists as a standalone. In other words, you
don't have to meet all of them. You could just meet one.
So it may be that in that situation the sole
community provider is not an appropriate exception for you. But
you could demonstrate that you are the majority provider for your
community which means that over 50 percent of your volume is Medicare,
Medicaid, or uninsured for the patient volume that you're handling.
And if each clinic can demonstrate that they
are meeting that majority criteria then the sole community criteria
becomes irrelevant.
(Mary Peterson):
But does the 30 miles
then kick in? The 30 miles - even though there is - say there's
four within 30 miles and they each can demonstrate one of the exceptions
they would each be able to have, maintain that Rural Health Clinic?
Bill Finerfrock:
Correct.
(Mary Peterson):
OK. So the 30 miles gets
kind of thrown out the window.
Bill Finerfrock:
In that particular - I
mean, I think that the - we are talking about the sole community
provider exception, correct?
(Mary Peterson):
Or majority. Is it the
majority of the community you're in or is it the majority of the
people within the 30 mile - I'm just going by any exception that
you may qualify for, whether I - we're in Town A, I qualify for
the sole community, in Town B I qualify for the majority. Does the
30 mile criteria kick in?
Bill Finerfrock:
You still have a - they're
still going to look at that criteria as far as who else is providing
care. But it's not - as I understand it - now some of this is obviously
going to be interpretation. And this may be something during the
new proposed rule that we will have to comment on because in many
ways we're getting a second bite at the apple.
What was in the proposed rule, some of the things
that ended being in the proposed rule were changed to the final
rule. So I can't answer your questions officially because I'm not
the one who's going to do the interpretation.
But based on our discussions it was felt that
clinics could demonstrate different criteria. And so this one might
be a specialty clinic, this one might be a majority clinic, et cetera.
I think the other thing is that how they calculate
your 30 minute is going to be a reflection of the kinds of roads.
So this may be a clinic that is 20 miles away, 15 miles away, and
would not be considered within your 30 minute window.
So I think the other thing is where are those
clinics located relative to you.
(Mary Peterson):
OK. Thanks.
Operator:
And moving on to our next
question.
Bill Finerfrock:
OK.
Operator:
Caller, go ahead. Your
line is open. No response. We'll move on to the next question.
Bill Finerfrock:
Who's next? Hello?
Operator:
Please go ahead, caller.
(William Hare):
William Hare, Maurice
Community Clinic in Louisiana.
Bill Finerfrock:
OK.
(William Hare):
I'm just trying to get
a little further clarification on the commingling. We're new into
the RHC program and we are a rural hospital under 50 beds.
Bill Finerfrock:
OK.
(William Hare):
And so this will be a
hospital based Rural Health Clinic.
Bill Finerfrock:
Will be or is?
(William Hare):
It will be. It's - we're
opening in February.
Bill Finerfrock:
OK.
(William Hare):
And we've already got
the designation, the rural designation and the non-urban certification.
Bill Finerfrock:
OK.
(William Hare):
This intends to be an
outreach program from our hospital in that we will establish the
Rural Health Clinic services as well as expand our radiology department
and our lab department to provide those services.
Bill Finerfrock:
OK.
(William Hare):
So what considerations
do I have for commingling with that scenario?
Bill Finerfrock:
Where will the lab and
x-ray be located?
(William Hare):
They will be located in
their own square footage.
Bill Finerfrock:
So you don't have a (clinical
issue).
(William Hare):
(In their own clinic).
Bill Finerfrock:
If they're not located
within the RHC then you don't have a commingling issue. It's what's
occurring within the four walls of the RHC. And if the radiology
and the lab are clearly occurring outside you don't have an issue.
Well, and then the other point is that radiology
and lab are not considered RHC services. So even with that you wouldn't
have a commingling issue because the technical component of both
lab and x-ray are not considered RHC services.
(William Hare):
OK. Thank you.
Operator:
And moving on to the next
question.
(Kathy Davis):
Yes. This is (Kathy Davis)
from Wellington, Kansas.
Bill Finerfrock:
Hi, Kathy.
(Kathy Davis):
A couple questions. My
first one is in regards to the decertification part. If you know
that you're already not in a shortage area or the rural health but
you're under the governor's designation, we are still subject for
decertification if you do not meet the four types of essential providers.
Is that correct?
Bill Finerfrock:
No. No, no. Let me understand
- if I understand your question. You are not a health professional
shortage area and medically underserved area but you are designated
by your governor
(Kathy Davis):
Correct.
Bill Finerfrock:
as a shortage area.
(Kathy Davis):
Correct.
Bill Finerfrock:
As long as that shortage
area designation is current you have - there would be no process
for decertification.
(Kathy Davis):
OK.
Bill Finerfrock:
You are in a current shortage
area. The decertification only would come into play if your clinic
is in an area that it is no longer considered a shortage area, which
is health professional shortage area, medically underserved area,
governor's designated shortage area
(Kathy Davis):
OK.
Bill Finerfrock:
or your shortage
area designation is out of date and cannot be brought into compliance.
(Kathy Davis):
I got you.
Bill Finerfrock:
If you have a valid shortage
area designation you don't have anything to worry about.
(Kathy Davis):
OK. And the governor's
exception or the governor is considered a valid shortage. I mean
that's just part of that whole definition of
Bill Finerfrock:
It's part of the underlying
definition
(Kathy Davis):
OK.
Bill Finerfrock:
of eligibility for
an RHC, health professional shortage area, medically underserved
area, governor's designated.
(Kathy Davis):
OK.
Bill Finerfrock:
It has to be current.
(Kathy Davis):
Right.
Bill Finerfrock:
You're not exempt from
the current requirement but it is a valid designation for purposes
of RHC.
(Kathy Davis):
OK. Right and one other
question. Just on the - like on the essential provider piece when
you're talking about specialty clinic - and I'm asking in particular
to the mental health services. Do you have to be specifically a
mental health clinic or an RHC that also provides mental health
services?
Bill Finerfrock:
No, an RHC that provides
mental health.
(Kathy Davis):
OK. So not necessarily
a mental - just a
Bill Finerfrock:
Right.
(Kathy Davis):
nothing but a -
OK. All right. Very good. Thank you.
Bill Finerfrock:
A Medicare Rural Health
Clinic that you are the only one in your area who's providing mental
health services.
(Kathy Davis):
So if you're - if you've
got a mental health service already in your community it wouldn't
be beneficial to be an RHC that provides
Bill Finerfrock:
Not for purposes if you
wanted to use that for the exception because you are not the sole
source.
(Kathy Davis):
Got you. OK. Very good.
Thank you.
Bill Finerfrock:
OK?
Operator:
And as a reminder that
is star one to ask your question today. And we'll move on to the
next question.
Bill Finerfrock:
Next one?
Sue (Morrison):
Hello. Hi. This is Sue
(Morrison) from Sparta Community Hospital in Illinois. We're provider
based. And I have a question back on when you lose a midlevel. Is
it that you have 90 days and if you don't replace then you go and
apply for the waiver for the year or do you apply for the waiver
right away?
Bill Finerfrock:
No, I would - I mean,
it's your call. I would generally do your due diligence, you know,
30, 60 days. If you're getting up on your 60 days and you really
are not having much in the way of response and you're concerned
that you're not going to be able to meet the 90, have someone on
board by 90 days I would initiate the communication with the state
survey and certification office at that point.
Say you are concerned that we're not going to
be able to meet the 90 day requirement. And we will probably need
a waiver. And go ahead and start it and get the waiver.
If you find someone in 30 days and they come
on board you can just give back the waiver. But if you need it it's
there and you can just continue operations. So I wouldn't wait until
the very end but I wouldn't go in immediately either and seek it.
For your purposes, I mean essentially what you
would be doing is losing several months of the waiver. The waivers
are routinely approved. There's really not a process for denying
a waiver request once it's been submitted.
So you effectively could go 15 months-your 90
days plus 12 months, while you are continuing to look.
Now I do want to point out to folks who may be
thinking that they do need a waiver. During the waiver period you
must be able to demonstrate that you are actively seeking to recruit
an employee, a PA, a nurse practitioner, and a nurse midwife during
the time of the waiver.
If at the end of the waiver you still have not
found a PA, nurse practitioner or nurse midwife the state will come
back and ask you for documentation to show what you did to actively
recruit to fill that position.
If you cannot demonstrate to the state that you
actively recruited for that position during the waiver period they
can make you - they can decertify you back to the end of your initial
90-day period.
So getting the waiver is important. It's easy
to do. But there are certain things you need to do during the waiver
in order to continue its validity.
OK? Next question?
Operator:
We have no further questions
in the queue.
Bill Finerfrock:
No. If we don't have any
questions or if anybody still wants to buzz in, we can take a few
more. We have a few more minutes on the call.
I do want to announce that there will be a transcript
of today's presentation available on the RHP Web site. Generally
we try and get it a week to 10 days but sometimes depending on how
quickly the transcript gets reviewed it slips a little bit.
I do want to encourage you to reach out to others.
If you think that there are other individuals who would find value
in participating in this conference call series please reach out
to them and encourage them to sign up.
The next call will be in mid-November and we
will be getting information out about that. As I mentioned I think
on the last call we're pleased to announce that this series has
been continued by the Office of Rural Health Policy. And we have
a - we've been approved for a five-year continuation. We'll be doing
six calls a year.
I also want to encourage folks to consider signing
up for the Rural Health Clinic list serve which is essentially an
e-mail or a list serve chat room, if you will, where you can post
questions, responses to questions, and create a network with clinics
from other parts of the country. And we get a very - we have a very
lively group of participants there. And we get some good discussions
going on a range of topics.
Are there any other questions at this point,
operator?
Operator:
Yes. We do have questions
in the queue.
Bill Finerfrock:
OK. Go ahead.
(Amber):
Yes. My name is (Amber)
from Kansas. And we're in the process of looking at setting up some
provider-based Rural Health Clinics.
Bill Finerfrock:
OK.
(Amber):
And in regard to the QAPI
program, what is your suggestion on that going into this process?
Should we - would that be something we look at setting up and establishing
as we set forth? Or would you say we should go with the program
evaluation at this time?
Bill Finerfrock:
Well, I would look at
the examples and the kinds of things that QAPI is going to be requesting
you to do and see whether or not there's some things that would
be relatively easy to do as you are setting up your clinic because
I do think it's easier to do some things if you incorporate it into
the operation at the outset rather than perhaps trying to change
your operation a year or so down the road.
But having said that, I would not do anything
that requires you to make a significant financial investment or
a change in your operations as an RHC because this is going to have
to go back through a rule making process.
I think the things that QAPI outlined are good
things to do, the things that you might want to consider doing even
if you weren't required to do them. But if you were - if you're
looking to do it as part of the setup I would look to do something
that's relatively simple to incorporate into your overall operations.
(Amber):
OK. Great.
Operator:
And moving on to our next
question.
Female:
Hello?
Bill Finerfrock:
Yes?
Female:
Bill, this is a little
off the subject but we were wondering if you will be doing another
teleconference on Rural Healthcare billing.
Bill Finerfrock:
I suspect that we will
be. We get a lot of requests for that. We had our advisory committee
call yesterday or the other day. And there were a couple of the
folks said we need to repeat topics because there's ongoing interest
in particularly billing and reimbursement kinds of things. So yes,
I can tell you that in all likelihood we will do that.
Where are you from? I'm sorry. I didn't hear
who it was.
Female:
We're from Sparta, Illinois.
Bill Finerfrock:
OK. Great.
Female:
Thank you.
Bill Finerfrock:
Yes.
Operator:
And moving on to the next
question.
(Beth Ann):
Hi, Bill. This is (Beth
Ann) from Michigan. And I just wanted you to go back over the midlevel
practitioner waiver because it's in my experience that you cannot
apply for that, you know, unless you have 90 days worth of documented,
documentation that says you've been recruiting.
So the state really won't even take a look at
that and process it to the regional office without a previous 90
days showing that you've actively been recruiting.
Bill Finerfrock:
Well, I appreciate that.
I had not experienced that nor had that communicated to me from
other states. But does that not create a time lag? I mean, is it
- what has been your experience in terms of how quickly they are
turning those requests around?
(Beth Ann):
Well, they scrutinize
the data on the documentation, you know, they really scrutinize
that. So they look to see when the practitioner left and at what
point then you started actively recruiting. They look at all of
the recruitment activity that you, you know, that you've done then
for the 90 days following the termination of that midlevel.
And then at that point it really takes them probably
another 60 days for it to go to the state, go to the regional office
and then for them to act on the request.
Bill Finerfrock:
Have you ever had a situation
where a request has been denied?
(Beth Ann):
I have had one denied
but that dealt with a CHOW which became a separate issue. I have
not had any besides that denied. But I have had them ask for additional
information. I've asked for them to have signed affidavits. They
wanted signed affidavits from the medical director or from the owner
of the clinic.
So I mean, they have come back and asked for
additional information to further document your efforts.
Bill Finerfrock:
Well, I think probably
the best thing to do for folks is when you lose your PA, your nurse
practitioners, nurse midwife, is contact your state survey and certification
office, let them know immediately that that has occurred and ask
them what their expectation is as far as actively recruiting during
the initial 90 days when they - if you are coming up and you are
unsuccessful what it is that they would expect you to do and when
they would be willing to accept a waiver application and just work
with your state to deal with that issue on a state-by-state basis.
Is that fair?
(Beth Ann):
Absolutely. Absolutely.
Bill Finerfrock:
Next question?
Operator:
Moving on.
(Dicey):
Hi. This is (Dicey) in
California. And we applied at the state level for a change of ownership.
And that has gone through but we have not heard from our regional
office. Is there a timeline that they have to get back to us by
or?
Bill Finerfrock:
I'm not aware of any timeline
requirements for a change of ownership application or form as far
as how quickly. There are some things that they have a timeline
that they have to approve within and if they fail to do that it's
automatically approved.
But I don't - I'm not aware of the application
of any of those deadlines to the CHOW. But you said the state has
approved it or?
(Dicey):
Yes. The state approved
it and sent it to the regional office. And I can't even get the
regional office to return my calls.
Bill Finerfrock:
I'm not sure - what type
of a change of ownership are you doing?
(Dicey):
We went from private RHC
ownership to a hospital.
Bill Finerfrock:
Provider based?
(Dicey):
Yes.
Bill Finerfrock:
Did you - did you fill
out all of the requisite criteria form for the provider based designation?
(Dicey):
Yes. We sent the whole
package to the state and the state did, you know, they kept it for
180 days and then sent it mid-September to the regional office.
And they won't even - I can't even get them to return my call to
say if I need to do anything or not.
I'm proceeding as normal. I haven't changed anything.
But I can't change - apply for a new rate or do anything until I
hear from them.
Bill Finerfrock:
You've got - you've got
two issues. One is change of ownership is typically just a notification
to the fiscal intermediary that there is a change in ownership.
In your case, however, going from an independent to a provider base
there are additional criteria that have to be verified and reviewed.
So I suspect that it's the fact - it's not the
change of ownership per se but the fact that you're going from independent
to provider base and the need to verify that you comply with all
the criteria to be provider-based.
And so I would just stay on the regional office.
If you want to send me an e-mail separately we may be able to do
some checking into it. Just send me an e-mail at info@narhc.org
and I'll see if there's anything we can do to try and figure out
what's going on.
(Dicey):
OK. Thank you.
Bill Finerfrock:
Yes.
Operator:
And moving on.
(Sherry):
This is (Sherry) from
Nebraska. And my question is about the PA having to be in the clinic
50 percent of the time.
Bill Finerfrock:
Yes.
(Sherry):
Was that like an initial
rule that was set from the beginning of Rural Healthcare or - because
sometimes it just seems like, you know, maybe a doctor could be
in there, you know, 60 percent of the time or 70 percent of the
time. And so why is that important that the PA be there 50 percent
of the time because sometimes I'll find that I have to have two,
you know, providers in there just so I can get that PA in there
50 percent of the time.
Bill Finerfrock:
Sure. It really goes back
to the inception of the program, the initial law that was adopted
back in 1977. It mandated the utilization of PAs, nurse practitioners,
and nurse midwives, actually PAs and NPs initially and subsequently
nurse midwives,.
So that is something when it was created by law
that the law has required and has always required in the nearly
30 years of operation. So, I mean, it's - you'd have to change the
law in order to change that. But that's the way the program was
designed.
(Sherry):
Do you ever get any complaints
about that, that maybe that isn't a good, you know, a good law to
have?
Bill Finerfrock:
We certainly have over
the years had some individuals question that. It's not something
that anyone has actively sought to change other than to reduce the
amount of time. The original was 60 percent as we discussed earlier
and then the law was changed to reduce that to 50 percent to allow
for some more flexible staffing.
That's the only change that I'm aware of that
ever looked at that staffing requirement. So it's certainly something
that people are free to raise. I can tell you that there are people
who feel very strongly that that requirement should be there.
It is the only federal program that mandates
utilization of physician assistants, nurse practitioners, or nurse
midwives unlike many programs that mandate utilization of physicians
and, you know - so it's a political decision.
(Sherry):
OK. Thank you.
Bill Finerfrock:
Yes.
Operator:
And there are no further
questions in the queue at this time.
Bill Finerfrock:
And I think that's about
the end of our time here, operator. So I want to thank everyone
for your participation today. We will have the transcript up on
the Web site, and that will be available for you to go back and
review.
If you do have questions in the future send them
to info, info@narhc.org. I want to thank the Office of Rural Health
Policy for their support for this Rural Health Clinic technical
assistance series.
And I want to remind everyone to encourage others
who may be interested to register for this program. The next call,
as I mentioned, will be in mid-November, and we will be putting
information out about that.
I do want to say that we will be looking to -
in the past we've been holding the calls at three o'clock. We will
be looking to conduct the calls at two o'clock Eastern time to try
and get it closer to the middle of the day that more people might
be able to do this over their lunch hour.
In the future I encourage you to try and call
in just a little bit early. It takes some time to sometimes get
through so that we try and get started right at the staring time
and don't take too much of people's times.
Again, thank you. I appreciate your participation.
Look forward to talking to you next month. Thank you.
Operator:
This does conclude today's
conference. We want to thank you for your participation.
END
|