Covered - Allowable - Billable TOP |
Slide 1: Covered
- Allowable - Billable
September
20, 2006
Presented by
Linda Dartt
207-589-3208
ldartt@fairpoint.net
|
Covered - Allowable - Billable TOP |
Slide 2: Goals for this Session
To
understand:
- What is an RHC Covered Service
- What is an RHC Allowable Service
- What is an RHC Billable Service
- RHC Services
- Part B Services
|
Covered - Allowable - Billable TOP |
Slide 3: Medicare Covered Services
Medicare Covered
Services Vary by
- Institutional Provider Type
- RHC
- IRHC
- PBRHC with Parent
- Hospital > 50 Beds and/or Not Rural
- Rural Hospital < 50 Beds
- CAH
- CHC/FQHC
- Hospital, CAH
- Home Health Agency
- Outpatient Department
- ASC
- Doctor's Office
|
Covered - Allowable - Billable TOP |
Slide 4: Medicare Covered Services
Medicare Covered Services Vary by (cont'd.)
- Individual Provider Type
- MD, PA, NP, HHN, HH Aide, CNM, CP, LCSW, EMT, Paramedic, etc. etc.
- Diagnosis
- Service Location
|
Covered - Allowable - Billable TOP |
Slide 5: Covered RHC Services
- Medicare
- Medicaid
- Medicare RHC Core Services
- Other services & providers as the State wishes (i.e. LSACs, LPCs)
|
Covered - Allowable - Billable TOP |
Slide 6: Core
RHC Services
- Medicare RHC Core Services Definition
- Arose from Historical Goals of the RHC Program
- Deliver Primary & Preventive care in rural areas that were perpetually short of doctors
- To encourage PAs & NPs to practice in rural shortage areas by paying them the same amounts as if a Physician had delivered the service (There were few CNMs at the time.).
- PAs &NPs were allowed to provide services & bill Medicare for covered services only when a Physician was on-site.
- Payment for PAs & NPs was less than 100% of the amount a Physician would have received for providing that same service.
- NPs were providing services through visiting nurse programs, especially in the Southeast. Mostly, States & non-profits paid for their services.
|
Covered - Allowable - Billable TOP |
Slide 7: Core RHC Services
- Medicare RHC Core Services Definition (cont'd)
- Became Law Through the RHC Act
- Allowed RHCs (rural primary care practices in areas with little or no physician coverage) to bill Medicare & Medicaid
- Allowed RHCs to receive interim payments at the average price for the practice to deliver a visit to a patient of any type with any or no insurance coverage, without regard to whether the Physician was present
- Assured that quality care would be provided to Medicare & Medicaid patients through a set of rules to govern RHCs
(Interpretive Guidelines, "annual" survey, surveyor forms, Policy Manual, etc., etc., etc.
|
Covered - Allowable - Billable TOP |
Slide 8: Core RHC Services
- Medicare-covered RHC = "Core" services
- 1977 Rural Health Clinics Act (PL 95-210) defined Core services
- Services of Primary care Physicians
- FP, General IM, GP, OB/GYN, Peds
- Services of PAs, NPs
- Services incident to* those primary care services
* Incident To describes those "Incidental services &
supplies" that are commonly part of a physician visit
& not chargeable. Incidentals are not Billable. AIRR (All
Inclusive Reimbursement Rate) -- average visit payment --
calculation includes the cost of incidentals through inclusion
of non-chargeable office, dressings, bandages, overhead, nursing
time, etc.
|
Covered - Allowable - Billable TOP |
Slide 9: Core RHC Services
- Medicare-covered RHC = Core Services (cont'd)
- Early RHC was "Easy"
- Practice "primarily engaged in the delivery of primary care"
- Bill by Encounter/Visit
- Face-to-face visit between a Medicare beneficiary
& an RHC provider for
- A medically necessary reason (documented)
- One patient, one date = Visit (exception for a new
diagnosis)
|
Covered - Allowable - Billable TOP |
Slide 10: Core RHC Services
- Medicare-covered RHC = "Core" services
- Amendments
- Added CNMs, CPs, LCSWs
- Services & supplies incident to* new RHC providers
- Endless "clarifying"
- Current definition of Core Services
- Physician services
- Deliver Primary Care (Present 1 day in each 2 weeks)
- Serve as Medical Director
- Provide State-required supervision of PAs, NPs & CNMs
- Services & supplies incident to physicians' services
|
Covered - Allowable - Billable TOP |
Slide 11: Core RHC Services
- Current Definition of Core Services (cont'd)
- Services of PAs, NPs, CNMs
- Services & supplies furnished as incident to services provided by PAs, NPs, CNMs
- Visiting nurse services - limited to Home Health
Shortage Areas Good Luck!
- CP & LCSW Services - Part B coverage limitations apply
- Services & supplies incident to services of CPs & LCSWs.
- RHC Core services can be provided at the practice, the patient's home, a boarding or nursing home, SNF, or at another health institution that is not a hospital.
|
Covered - Allowable - Billable TOP |
Slide 12: Medicaid
Covered Services
- Federally Required "Core" RHC Services
- Optional Medicaid-Covered Services, as defined by State law
- Medicaid Allowable Costs are Different in Each State
- Medicaid Billing Policy is Different in Each State
|
Covered - Allowable - Billable TOP |
Slide 13: Allowable
Costs
- Allowable is Cost Reporting Terminology
- Result from providing covered services
- Are reasonable in amount
- Necessary to efficiently deliver covered services
- Include direct costs (salaries, supplies ++) to provide covered services
- Include allocated portion of overhead (administration, facility ++)
|
Covered - Allowable - Billable TOP |
Slide 14: Allowable RHC Costs
- Medicare Allowable Cost rules follow Medicare Benefit Policy Manual #100-02
http://www.cms.hhs.gov/Manuals/IOM/list.asp
- Medicare Allowable varies by
- Institutional provider type
- Individual provider type
- Medicare RHC Allowable Cost rules are in the RHC/FQHC Manual
|
Covered - Allowable - Billable TOP |
Slide 15: Allowable RHC Costs
(cont'd)
- Medicaid Allowable Policy follows State law & regulations
- Covered Services
- Billable Services
- Billing Methodology
- Co-payments
- Deductibles
- Minimum spending amounts
|
Covered - Allowable - Billable TOP |
Slide 16: Non-Allowable Costs
|
Covered - Allowable - Billable TOP |
Slide 17: Non-Allowable
Costs
- Direct Costs & allocated non-direct costs of delivering non-covered services are excluded from allowable RHC cost used to calculate AIRR
Ex: Patient transportation (not covered by Medicare, may
be covered by Medicaid)
- Direct costs such as gas, maintenance, driver, ++
- Indirect costs such as office space, telephone, ++
|
Covered - Allowable - Billable TOP |
Slide 18: Billable
RHC Services
- Encounters delivered by a Billable RHC Provider
- MD, DO, other State-recognized "physicians"
- PAs, NPs, CNMs
- CPs & LCSWs
- Visiting Nurses (in designated Home Health Shortage
Areas)
- Clinical Psychologists (Medicare coverage limitations
apply)
- Licensed Clinical Social Workers (Medicare Part B coverage
limitations apply)
For Covered Services ONLY
|
Covered - Allowable - Billable TOP |
Slide 19: Billable
RHC Services
- Billable Visits
- An RHC billable visit is "a face to face encounter between a patient and a… covered service provider…"
- All patient encounters will not be billable visits
- Exs: Lab or x-ray services, with no "face to face encounter" with a covered
RHC provider, do not constitute an RHC visit & cannot,
by themselves, generate a bill.
- All Lab services are billed to the Medicare Part B Carrier as Lab services are not considered RHC services, including the 6 mandatory laboratory services.
|
Covered - Allowable - Billable TOP |
Slide 20: Non-Billable
RHC Services
- Non-Billable "Visits"
- Billing an RHC encounter for refilling a prescription is specifically forbidden (RHC Manual, Part 4, Section 405.3) whether the patient sees a provider or not. Billing for refills is not covered.
- If the manual did not define this as non-covered & not billable, it wouldn't be because there is no medical necessity for the patient to see a billable RHC provider
- Theoretically, the direct & indirect costs of providing these services (reception, nurse, space, telephone ++) should be allocated to non-allowable costs because they belong to non-covered services.
- In reality, this is just part of the overhead of running a practice, which is why a percentage of overhead is allocated to covered & non-covered service costs when calculating the AIRR.
|
Covered - Allowable - Billable TOP |
Slide 21: Non-Billable
RHC Services
- Services delivered by telephone are not currently Billable, but stay tuned.
- Many telephone-delivered services are Covered & are therefore Allowable on the cost report
- Many telephone-delivered services are not Covered & are therefore Non-allowable
- Anything that does not involve
- A Face-to-Face Encounter with an RHC Billable Provider
- Medical Necessity for a Face-to-Face Encounter with the Patient
- Medical Judgment documented in the patient record
|
Covered - Allowable - Billable TOP |
Slide 22: AIRR = Allowable Cost ÷
Billable Visits
- Cost-based reimbursement assumes Medicare & Medicaid will pay a fair share of total RHC costs to deliver covered services.
- Total reimbursement is based on the % of Medicare & Medicaid covered visits provided.
- Medicare sets & uses the AIRR to pay for each Billable visit
- Medicare pays 80% of the AIRR for Covered, Billable services because 80% is the patient benefit level for almost all Medicare-covered services
- AIRR is limited by cost-controlling factors such as productivity expectations & per visit payment caps (depending on parent provider type).
|
Covered
- Allowable - Billable TOP |
Slide 23: AIRR ⇒ Cost Settlement
⇒ AIRR
- At the end of each fiscal year, Medicare & the practice "settle" their bill
- Practice (or parent) submits a cost report on covered costs & visits.
- After applying limiting factors, Medicare (or the practice) pays the difference between total due total received through AIRR payments.
- The AIRR is reset, taking into account the current cap & the reported costs
|
Covered
- Allowable - Billable TOP |
Slide 24: Medicaid
- Currently, Medicaid uses the Medicare AIRR as a guide
- After including required & optional services, Medicaid decides how much to pay the RHC
- Must make interim payments (encounters)
- There are some limits
- Must pay a reasonable rate, based on cost, for Core services
- See www.medicare.gov
- Everything about Medicaid varies by State & it is evolving away from any consistency that existed at one time
|
Covered
- Allowable - Billable TOP |
Slide 25: Finally
- Make friends with the people who decide policies & oversee coverage & billing within your State government.
- Attend Hearings & Informational Meetings.
- Do NOT Be Afraid to Ask Questions.
If you think you are too small to make a difference, try sleeping in a closed room with a mosquito.
African Proverb
|
Covered
- Allowable - Billable TOP |
Slide 26: Acronyms Used in this Presentation
+
ASC = Ambulatory Surgical Center
CAH = Critical Access Hospital
CHC = Community Health Center
(receives funding through HRSA - §330 of SSA)
CNM = Certified Nurse Midwife
CP = Clinical Psychologist
EMT = Emergency Medical Technician
FQHC = Federally Qualified Health Center
Look Alike
CHC
HHA = Home Health Agency
|
Covered
- Allowable - Billable TOP |
Slide 27: Acronyms Used in this Presentation
(cont'd.)
HHN = Home Health Nurse
HHA = Home Health Aide
HMO = Health Maintenance Organization
HRSA = Health Resources & Services Administration
LCSW = Licensed Clinical Social Worker
IM = Internal Medicine
NP = Nurse Practitioner
aka AP (Advanced Practice) RN, other Master's level, State-approved
RN practitioners
OPD = Hospital Outpatient Department (including CAH)
|
Covered
- Allowable - Billable TOP |
Slide 28: Acronyms Used in this Presentation
(cont'd.)
Paramedic = Someone trained, usually by military, to deliver
high level, emergency & urgent care
Currently mostly Ambulance Employees
PA = Physician Assistant
PPO = Preferred Provider Organization
PoSP = Point of Service Plan
RHC = Rural Health Clinic
IRHC = Independent RHC
PBRHC = Provider-Based RHC
SNF = Skilled Nursing Facility
SSA = Social Security Act
|