Operator:
Good day everyone and welcome to this RHC the
basics part two conference call. As a reminder, today's call is
being recorded.
At this time, I would
like to turn the conference over to your host, Mr. Bill Finerfrock.
Please go ahead, sir.
Bill Finerfrock:
Thank you, Operator. My name is Bill Finerfrock.
I'm both the moderator and the speaker for today's call. I'm the
Executive Director of the National Association of Rural Health Clinics.
This is part two of our RHC's the basics.
Our previous call about
two weeks ago looked at location issues and those slides are available
and a transcript of that call will be available shortly. Today's
call, as you heard, is being recorded and a transcript of today's
call will be available probably in a couple of weeks.
I want to welcome everybody
to today's call and I also want to say that these calls are being
sponsored by the Federal Office of Rural Health Policy and we thank
them for the generous support of this series.
Today's program is scheduled
for one hour. The first 45 minutes will consist of my presentation
and the remaining 15 minutes will be dedicated to questions and
answers. As I said, this is sponsored by the (ARCA) Office of Rural
Health Policy in conjunction with the National Association of Rural
Health Clinics. The purpose of the call is to provide RHC staff
with technical assistance and RHC-specific information.
Today's is the tenth call
in a series which began in 2005. There is, as you know, no charge
to participate. Individuals can sign up to receive announcements
regarding the call dates, topics, and speaker presentations and
that can be found at www.ruralhealth-one word - R-U-R-A-L-H-E-A-L-T-H.H-R-S-A.G-O-V/RHC.
During the question-and-answer
segment of the call, we'll request that callers provide us with
their name and location they're calling from prior to their question.
And in the future, you can also e-mail questions or topic suggestions
to info - I-N-FO- .narhc. Put teleconference question in the subject
line. We will make every effort to answer those questions and post
it on the NRHC Web site, which is www.narhc.org.
Today's call is going
to focus on operational issues - basic operational issues for your
rural health clinic. As I did on the last call, I want to encourage
you to go to the Web site - the NARHC Web site and download the
starting a rural health clinic, a how-to manual document that will
go through many of the issues that we discussed last week - or two
weeks ago and we'll be discussing today. You can get that through
our homepage, which is www.narhc.org. And in the slides, I provided
you with the specific link to that document. It's in a PDF format
and can be downloaded and printed at your site.
Some of the things we're
going to cover today include the RHC staffing requirements, the
role of the policy and procedures' manual, the role of the cost
report, and the definition of an RHC visit. I do want to, you know,
point out that this is the basics. Because we only have 45 minutes,
we're not going into a lot of great detail on these subjects. We
have on some of these in the past and we will in the future but
we will not be going into tremendous detail because of the time
limitation.
Some of the other issues we'll be talking about is the definition
of what is an RHC visit, what about ancillary services, visits to
the hospital, and visits to a nursing home.
In terms of the RHC staffing,
the Rural Health Clinic program is predicated on a team approach
to healthcare delivery and there is a link again on our Web site
to the rural health clinic rules and interpretative guidelines that
you can go and download. And I - and I would encourage you to a
minimum download the interpretative guidelines but to also establish
the link to the RHC rules that are available there. Those are the
official documents. The rules are the official requirements for
the RHC program. Anything other than that is either interpretative
or whatever. The RHC rules, what is in the code of federal regulations
are what you must follow for purposes of the RHC program.
All of the surveyors when
they come to inspect the facility will determine whether the Rural
Health Clinic is sufficiently staffed by the RHC rules in the code
of federal regulations to provide services essential to its operation.
Because clinics are located in areas that have been designated has
having a shortage of health personnel, they frequently aren't able
to employ what would be considered adequate or sufficient healthcare
staffs that you might find in many other settings, and as a result
of that, we find that there is often turnover within the RHC community
with regards to the physicians, the PAs, the nurse practitioners,
the nurse midwives, et cetera.
Every Rural Health Clinic
must have a physician who serves as the medical director and it
must have a physician assistant, or a nurse practitioner, or a certified
nurse midwife on site and available to provide care at least 50
percent of the time that the clinic is open and I'll go into that
in a little bit more detail.
Should the loss of a physician,
a physician assistant, certified nurse, midwife, or nurse practitioner
member of the RHC staff reduce the clinic's staff below the minimum
required, the clinic will be afforded a reasonable time to comply
with your staffing requirement. Now, typically, what that means
is that you will have initially 90 days to replace your PA, your
nurse practitioner, or your certified nurse midwife and you would
not be considered to be out of compliance with the PA, NP, nurse
midwife staffing requirement.
And then after the initial
90 days, if you - as you're approaching your 90-day requirement,
if you determine that you will not have a new PA, nurse practitioner,
or nurse midwife on staff by the end of that 90 days, you can apply
for a waiver of the staffing requirement and that waiver is good
for one year. So if you lose your PA, your nurse practitioner, or
your nurse midwife, you actually have a year to three months to
replace that person if you do the request and the paperwork before
you would be considered to be out of compliance with that requirement.
Now that waiver is only
available to clinics that are already in the program. You cannot
seek a waiver concurrent with your initial application to become
a Rural Health Clinic. You must be able to demonstrate at the time
of initial certification that you meet the RHC staffing requirement.
Should you get a waiver of your staffing requirement, you must be
able to demonstrate during the period of the waiver that you are
actively seeking to recruit and employ a PA, a nurse practitioner,
or a nurse midwife during that time period.
If at the end of you -
if you get to the end of your waiver and you still have not found
an individual to fill that requirement and the surveyors ask you
for the documentation that you have been actively recruiting for
the previous year and you are unable to provide that, then you are
subject to decertification as a Rural Health Clinic back to the
end of the initial 90-day period. It is a subjective process in
terms of demonstrating that you were actively recruiting but you
should be able to show that you took out ads in publications where
PAs, nurse practitioners, or nurse midwifes would likely be looking;
you contacted educational programs for the disciplines in question
so that you could solicit or try and get new graduates.
I did have a clinic at
one time who contacted me that was being told that their decertification
was going to be subject to the - prior to the commencement of the
waiver period, and when I asked them what they had done to show
that they had been actively recruiting, they said that they had
taken an ad out in their local newspaper. Now this particular clinic
was in a town of 3,000 people and that was all that they had done.
I suspect that if there was a PA, a nurse practitioner in a town
of 3,000 people they probably knew who they were, let alone had
the ability to contact them. So simply taking out an ad in their
local newspaper was not sufficient to show that they were actively
trying to recruit to fill that position.
As I said, it is only
available to existing clinics and it is also not renewable in terms
of the initial waiver. If you were to find a person, fill the spot,
then subsequently lose that person, you could come back for a waiver
later on but the - a waiver in and of itself cannot be extended
beyond (the) one-year time period. So your staffing should always
be one or more physicians, one or more PAs, NPs, or CNMs, and your
PA, nurse practitioner, or nurse midwife must be on site and available
to see patients 50 percent of the time that the clinic is open for
patient care so that the -on a full-time equivalent, if your clinic
is open for 40 hours a week then you must be able to show that you
had a PA, nurse practitioner, or nurse midwife onsite and available
to see patients 20 hours of that 40-hour period.
The surveyors are given
some latitude as to the time period that they are to look at as
far as meeting the 50-percent staffing requirement. If it makes
sense to look at it on a weekly basis or a monthly basis, they have
the flexibility to do that so that if your PA or your nurse practitioner
is simply gone for a short period of time - you know, they're gone
three days out of the week for a particular situation that arose,
it was unexpected, it's not as if you are out of compliance because
they weren't there two and a half - more than two days that week.
You could look at it for that whole month. So if your PA goes on
vacation for a week, again, it's not a situation where you're going
to be hit with a deficiency because they can look at it on a monthly
basis.
In terms of your physician,
your physician will serve as the - as both a healthcare provider
and a medical director. The physician must be onsite and available
to see patients at least one day every two weeks unless greater
onsite availabilities required by state law or state regulatory
mechanism governing PA, NP, or CNM practice. The one-day/every-two-weeks
is literally eight hours so that - I just got an e-mail this morning
from a clinic that, for various reasons, their physician will only
be able to be there now four hours every week instead of - I think
it was 20 to 30 hours they had been there and they were asking if
that would be a problem. Since it's four hours every week that would
be eight hours with in a two-week time period which would meet the
one-day/every-two-week time requirement so that is not a problem.
You can - it doesn't have to be one day all at one time as long
as you meet the total of one day, every two weeks that would sufficient.
They do have flexibility.
Your surveyors do have flexibility on the availability requirement
when there are extenuating circumstances. These would include an
illness, extreme weather, driving conditions of short duration,
or those emergencies which occur in the physician's practice and
would require his or her presence elsewhere. When non-recurring
circumstances cause postponement of the physician's visit, they
should be documented in the clinical records.
So if your physician were
to become ill and was not able to get to the clinic during a particular
week - that four-hour timeframe - they were scheduled to be there
that particular week they couldn't get there because of an illness,
again, that in and of itself would not be sufficient to justify
a violation but you want to document it as to the reason for the
absence and be able to show that this was a non-recurring situation.
Same thing; we have some
clinics that may be 80 or 90 miles between where the supervising
physician's full-time practice is where the Rural Health Clinic
is, there may be weather issues that would prevent the physician
- during the winter months, for example, roads are closed and the
physician can't get to the clinic to fulfill that requirement. Again,
those would be acceptable reasons for not fulfilling that requirement
on a non-recurring basis and you would need to document that as
well.
Those are the non-recurring
situations. There are also circumstances under which the physician
would be unable to be at the clinic on a recurring basis and those
too can be approved for a waiver. Those must come from the CMS regional
office. And some of the examples of what would justify a waiver
would be the remoteness of the clinic makes frequent travel impossible
or unreasonable; the remoteness of a physician member's location
has already placed the physician in a shortage area and required
visits at least once every two weeks would severely detract from
the physician's practice;, or if it is clearly established in advance
that continuing conditions are known to be expected, snow, flood,
Louisiana had Hurricane Katrina, examples of things like that. Perhaps
there's a bridge that you must cross in order to get from where
the main clinic is to where a Rural Health Clinic would be and that
bridge is closed which would make travel difficult, if not impossible.
These are all reasons why you could get the staffing - the physician
availability requirement waived or modified but you would need to
work with the - with the CMS regional office on that.
One of the ones I want
to focus in on here, and this tends to be the most common reason
for the waiver, you have a physician who is located in a shortage
area and you have a Rural Health Clinic that's located in perhaps
a different underserved area, and when the physician would leave
his or her practice to go to do the supervisory requirements at
the Rural Health Clinic would mean that healthcare is not available
in the community where the physician would normally be practicing.
And so the program has the flexibility to say, well, it doesn't
make a whole lot of sense to have created a situation where the
physician has to leave community A which - where he or she is the
only healthcare provider to go to community B where they have a
physician assistant or nurse practitioner or nurse midwife to fulfill
a staffing requirement to where now you've got a physician and the
PA or the physician and the NP and leave community A uncovered.
And so, if that's the
situation that you would find yourself in, you can go to the regional
office and you can ask for a waiver of the staffing requirement
and demonstrate that that type of a situation exists and the opportunity
would exist for a waiver. It is a subjective process again, as are
many of the things in this program. It would be up to the regional
office to make the determination that waiving that requirement does
- would constitute a hardship but they do have the authority to
do that.
The RHC model is based
on the presumption that a significant amount of the care is in fact
going to be provided by the nurse practitioner, physician assistant,
or certified nurse midwife. Now because of that, there's an area
of the program that has caused tremendous confusion, some problems
I do want to touch on.
Under the current requirements,
all Rural Health Clinics must employ at least one physician assistant,
or one nurse practitioner, or one certified nurse midwife who is,
as I said before, onsite and available to see patients at least
50 percent of the time. The word employ here is used in a very specific
context and it means that there must be a (W-2) relationship between
the owner of the clinic and the PA, the NP, or the nurse midwife.
The only situation in
which the employment arrangement would not be there would be if
the PA or the NP or the CNM was the actual owner of the clinic,
in which case, obviously, there would not necessarily be an employment
relationship as the owner. But if there's a situation - any situation
other than where the PA or NP or CNM is the owner of the clinic,
then there must be at least one PA, or one nurse practitioner, or
one nurse midwife who is employed by the RHC in order to meet that
requirement.
Now there is some disagreement
with regard to situations where you have more than one nurse practitioner,
nurse midwife, or physician assistant employed by the RHC and whether
those additional personnel also have to be employees or can they
can be contracted individuals to the RHC. There are different surveyors
who take different - a different position and we are trying to get
some additional clarification out of CMS central office.
There is some disagreement
over whether or not every PA, nurse practitioner, or nurse midwife
must be an employee or whether only the one. We know that at least
one must and we will try and get additional information out as there's
more clarity with regard to the additional personnel, but you must
at least have one PA, nurse practitioner, or midwife who is an employee
in order to meet that staffing requirement.
Now one of the other areas
that sometimes comes up and there's confusion about is what does
it mean when it says available to furnish patient care. This means
that they are providing RHC services in the clinic, that they are
physically present in the clinic even though they may not necessarily
be providing services, or they are providing RHC services to clinic
patients outside the clinic. In other words, they've gone a to patient's
home, they've gone to someplace else where they're actually providing
care to an RHC patient.
But the key is, number
two, is physically present in clinic even though they're not providing
services. If your PA, or your nurse practitioner, or nurse midwife
is there and available to provide care even if they did not necessarily
have a full schedule that day or for whatever reason didn't see
patients that day but they were available to, that can be counted
as meeting that staffing requirement.
In terms of the provision
of services, each Rural Health Clinic must be capable of delivering
outpatient primary care services. This comes up. Sometimes people
say, well, are we allowed to provide surgery, are we allowed to
provide other procedures. Yes you can provide those additional services
but you must be able to identify that you can provide primary care
services in your clinic and you must maintain written patient care
policies. This is what is often referred to as the policy and procedures'
manual.
The policy and procedures'
manual must be comprehensive enough to cover most health problems
that patients will usually see a physician about. In that book,
I referenced that the outset is a sample policy and procedures'
manual. I want to emphasize that it is a sample; it's a guide. Each
policy and procedures' manual should be clinic-specific. It is a
written description of how you intend to provide care in your clinic.
It is a written description of the relationship that will exist
between the physician and the PA, or the physician and the nurse
practitioner, or the physician and the nurse midwife, and every
situation is going to be different and have to reflect the unique
circumstances of what exists in your community and how you intend
to provide care.
You must include in there
- you must describe the medical procedures available to the nurse
practitioner, or certified nurse midwife, and/or PA, what is it
that they're going to be doing, describe the medical conditions,
signs or developments of required consultation or referral, what
happens when a patient comes in that the PA may not be able to treat
or wants to refer, what happens when a patient comes in and the
physician wants to refer because the physician isn't comfortable
providing care for that particular patient.
And your requirements
must always be compatible with applicable state laws. You can't
have in your policy and procedures' manual that your PA will maintain
telephonic communication most of the time except for when the physician
is onsite one day every two weeks if your state law requires the
physician to be onsite more frequently. You can never override your
state law requirements. You must always be in compliance with your
state law.
If your state law requires
a minimum of patient charts for care provided by your nurse practitioner
must be reviewed by the physician, then that has to be consistently
included in your policy and procedures' manual. It doesn't give
you the right to supersede state law or any federal requirement.
They must at a minimum be in compliance with state the law, but
again, you want it to be an accurate reflection of what you intend
to do in your practice.
The policy and procedures'
manual, as I said, is a written description of how you intend to
deliver care in your practice. It will describe the relationship
between the physician and the PA, the physician and the nurse practitioner,
physician and other personnel. Even if - and this is one of the
areas I've had from people and they've said, well, why do we have
to do a policy and procedures' manual, and in my view, I think it's
a document that every practice should have that is going to utilize
PAs, or nurse practitioners, or others, you know, how do you intend
to deliver care.
It's a good document to
have you put down on paper how you plan to deliver care in your
practice; what are the relationships, what are the referral requirements
going to be, or expectations going to be. It also serves as a good
teaching document when you bring in new staff, that they can have
a full, complete understanding of how you are providing care in
your particular clinic, what the particular relationships are between
the different professionals, and it can serve as a good educational
tool for new staff.
Policy and procedures'
manual must be developed jointly by the physician, or your PA, your
nurse practitioner, or your nurse midwife, (and) one other health
practitioner who's not a member of the clinic staff. In many situations
this may be the local pharmacist who is available to your clinic.
Someone who has a healthcare background who can be an outside set
of eyes and ears to help you provide - perhaps think about some
issues that you wouldn't have. But, this is a document that the
staff has put together collaboratively.
It is not a document that
is intended to be put together by one person who says, you know,
this is the way it is, take it or leave it. It has to be developed
collaboratively and your documentation must demonstrate that it
was developed collaboratively. When your surveyors come in they're
going to want to know that this was a collaborative effort between
the various folks who would be involved. As I mentioned, the sample
is available on our Web site.
In terms of the physical
plant of the clinic, a Rural Health Clinic may be permanent or mobile.
We do have some mobile Rural Health Clinics around the United States.
There's not a huge number of them but the law and the regulations
do provide that the clinic can be mobile. There are specific requirements
that a mobile clinic must meet. Unfortunately, time doesn't allow
us to go into that, but if that's something where you're trying
to serve a large geographic area, you might want to consider.
Also, a Rural Health Clinic
can be owned by any entity that is authorized to own a medical practice
by the state in which the clinic is located. So as long as state
law allows an entity, whether it's a community, whether it's a physician,
a hospital, a physician assistant, or a nurse practitioner, or somebody
else who can own a medical practice, the Rural Health Clinic program
defers to state law as far as that is concerned.
RHCs can be either a for-profit
or a not-for-profit entity. It is not required to be a nonprofit.
This is something we've gotten from people over the years: do I
have to be a nonprofit? No, you do not. You can operate it as a
for-profit entity and it also maybe either a provider-based or independent.
Now, that is where some confusion - what does it mean to be provider-based.
Provider-based means that
it's owned and operated by any entity defined by the Medicare statute
as a "provider". Now provider, in lay terms and in general
conversation is a all-encompassing term, but for purposes of this
particular section of the law has a very specific meaning and that
is going to be either a hospital, skilled nursing facility, or home
health agency. Those entities defined by the Medicare statute as
a "provider."
The criteria for a facility
being defined as provider-based is not unique to the RHC program.
You can have any type - many multiple types of provider-based entities
and the standards apply to any of those of which Rural Health Clinic
is one. Included in your slides is a link to the criteria that must
be met in order for a facility to be considered provider based.
When a Rural Health Clinic
is initially surveyed, you're surveyed as a Rural Health Clinic.
Whether or not you are subsequently defined as a provider-based
Rural Health Clinic is determined by the fiscal intermediary in
conjunction with the CMS regional office and based on your ability
to demonstrate that you meet the specific criteria for being provider-based.
And again, that is not unique to the RHC program.
Some of the things that
will be looked at in making the determination of whether or not
you're provided-based is the licensure of the facility, the types
of clinical services that are going to be provided, the level of
financial integration between the Rural Health Clinic and the parent
provider. The public awareness, do you hold yourself out to the
public as being formally part of a hospital, a nursing home, or
a home health agency, or is there simply a sign out front that says
this is the Smithville Rural Health Clinic but no indication that
there's any formal connection to, for example, a hospital in your
community.
One of the requirements
of being provider based is that you actually hold yourself out to
the public as being part of the provider, that it is not something
where you have simply sought provider-based designation in order
to get better reimbursement in this case but are in fact fully a
part of the provider.
Typically, the questions
are going to arise when the RHC is off campus. If the RHC is on
campus there's going to largely be the presumption that you are
provider-based and so there's going to be a higher level of scrutiny
for those facilities that are located off campus. When you're operated
under the ownership and control of the main provider there must
be specific reporting relationships between the facility seeking
provider-based status and the main provider and you essentially
must be treated, even though you're not on campus, as if you were
a department of the provider with the same level of frequency, intensity,
level of accountability that exist in the relationship between the
main provider and one of its existing departments.
Again, it's not a situation
where a hospital has said, well, we're going to own you and we're
going to tell everybody that you're part of us but we're somehow
going to treat you differently in terms of financial integration,
the organizational integration, et cetera. You're going to have
to demonstrate that even though you're not physically at the hospital
and you're 30 miles away that there is a similar level of integration
had you been there physically onsite.
Now there are some distance
requirements if your facility is located within a 35-mile radius
of the campus of the provider and criteria for facilities located
more than 35 miles from the parent provider. These can be found
in the program memo referenced above. And again, for time limitations,
we don't have the time to go into that. If you have something you're
looking at, I would encourage you to look at the program memorandum
for which there was a link provided and you can check that out.
Clearly, we have many provider-based RHCs that are more than 35
minutes - miles away from the parent provider that it is something
you will need to look at to make sure that you can meet those criteria.
Independent Rural Health
Clinics are those Rural Health Clinics that are not designated as
provider-based. In other words, every Rural Health Clinic is considered
an independent RHC unless it separately applies for provider-based
designation. You can have a hospital that owns and operates a Rural
Health Clinic that is an independent RHC. The mere fact that the
hospital owns it does not make it provider-based. Unless they meet
the criteria, it can still be an RHC, it's just that at that point
it would be an independent RHC owned by the hospital as opposed
to a provider-based RHC owned by the hospital, and, you know, you
must meet those criteria.
The direct services that
must be provided by your clinic staff are the diagnostic and therapeutic
services, as I mentioned earlier, commonly furnished in a physician's
office. You must be able to demonstrate that you can provide basic
laboratory services. There are six tests that every Rural Health
Clinic must demonstrate that they have the ability to provide those
tests: chemical examination of urine, hemoglobin or (hematocrit),
a blood sugar test, examination of stool specimens for occult blood,
pregnancy tests, and primary culturing for a transmittal.
Now one of the areas where
there's been some confusion is where the clinic, as I said, must
demonstrate that they are able to perform these tests but this does
not preclude the RHC from sending those tests out to a referenced
lab or other lab if it is considered more cost effective. In other
words, just because you have the ability to do it doesn't mean that
you have to if you can do it more efficiently elsewhere but you
do have to demonstrate the ability to provide those tests onsite
if requested.
There's also, as many
of you know - I'm sure there are billing issues. Although those
are required to be performed by an RHC or available, the lab services
are not considered RHC services so they do not get covered under
your all-inclusive rate. You must be able to provide emergency services.
By this, it means first response to common, life-threatening injuries
and acute illnesses. You are not expected to be an emergency room
but you should be able to provide first response to common, life-threatening
injuries or acute illnesses and you should have available drugs
used commonly in lifesaving procedures.
Now we very often get
questions, well, what specific drugs do we have to have. I would
talk with your state surveyors about what their expectation is because
it's going to vary from community to community or state to state;
again, whatever may be reasonable in terms of your particular situation
and how you may handle it in your community. What is available in
some communities - they're very remote, sparsely populated with
very limited staffing is not going to be held to the same standard
as a clinic that is in a larger community that has a higher level
of care available or more providers available.
You can provide services
through arrangement and they can be provided by individuals other
than the clinic staff. That would be in-hospital care - inpatient
hospital care, specialized physician services. You can have a specially
physician come into your clinic and provide care, specialized diagnostic
and laboratory services, interpreter for foreign language - you
will need to be able to demonstrate that but that can be done through
arrangement - or interpreter for deaf and devices to assist communication
with blind patients or deaf patients. You're going to have to be
able to demonstrate that if you have individuals who show up with
a language impairment that you have an ability to get appropriate
communication for those individuals.
Maintaining of patient
health records, your record system is going to be guided by your
written policy and procedures' manual. You're going to have to have
a designated person - - not necessarily a health professional -
- a designated professional staff member who's responsible for maintaining
those records. And those records are going to be required to have
specific information within - which will include also the fact that
you are maintaining the confidentiality safeguards against loss,
destruction, or unauthorized use.
Now much of this is familiar
to most practices today because of the HIPAA requirements that have
been in place in the last few years, but the fact is that RHCs have
been under some form of requirement in terms of safety and security
of medical records since the inception of the program so this really
is almost redundant in many ways. If you are HIPAA compliant, you
should be in compliance with the RHC requirements with regard to
the confidentiality and safeguarding of the record.
The written policy and
procedures' manual must also talk about the governing use and removal
and release of information, who will have the ability to have access
to that information, how is it going to be removed, who will it
be released to, and the circumstances under which it will be released,
and you must have written patient consent in order for records to
be released. Again, the RHC requirements predate the HIPAA requirements
so none of this should come as unique now to the RHC program but
they are requirements.
Now I'd like to talk a
little bit about the RHC cost report. The RHC cost report is your
financial audit of your practice and it's going to be looking at
both costs and visits to determine the average cost per visit for
each Rural Health Clinic. In the RHC manual that I've referenced
several times now is a sample of a completed RHC cost report so
that you can go in there and actually see how the RHC rate for that
particular clinic was determined, the kinds of information that
was required, and how those numbers move from column to column and
chart to chart and ultimately end up with your average cost per
visit.
Some of the things you
do need to have available when you do a cost report would be include
the hours of operation of the facility as an RHC and the hours of
operation of the facility as a non-RHC and I want to spend just
a second on this particular area.
You can have your clinic
open five days a week, six days a week, two days a week. The fact
that you are certified as a Rural Health Clinic does not mean that
you have to be certified as a Rural Health Clinic during all those
hours of operation. For example, if your clinic is open Monday through
Friday you can have it designated as a Rural Health Clinic on Monday,
Wednesday, and Friday and you're not a Rural Health Clinic on Tuesday
and Thursday.
Now for those of you who've
looked at this, it can have significant financial implications,
in some cases positive, for your clinic but you're not required
to be a Rural Health Clinic during all of the hours of operation
of your RHC. Maybe you're an RHC five days a week but from 9:00
in the morning till 5:00 in the afternoon and then you have evening
hours for walk-in patients and from 6:00 till 9:00 you're not an
RHC. Those create some particular challenges for the people who
are doing your cost report but it is permissible. You just simply
have to be able to note on your cost report the hours of operation
as an RHC and the hours of operation during - as a non-RHC.
You're going to be able
to have information on the compensation for your clinic's staff
broken down by a provider type, both health professional and administrative;
what are - what is your compensation for physicians, what is your
compensation for physician assistants, nurse practitioners, what
is your compensation for the receptionist at the front desk. All
of that will be broken out into your cost report and part of the
calculations. Your physician - and this comes up because compensation
is a very broad term. It does not look exclusively at salary. It
may be bonuses; it may be various things that you've done to incentivise
efficiency. Those are all part of the compensation package for your
physician, or your PAs, or you nurse practitioners.
You're going to have to
have your information on your medical supplies; what medical supplies
do you keep on hand and what are your costs. Those will all go into
your cost report. The cost of facility overhead, what is your rent,
if you rent the building, what is your interest - mortgage interest
payments if you own the building, what's your insurance costs, what
are you paying for utilities. Those will all go into your cost report
and then you're going to need - so you're going to need to have
all of that information for the overall cost to operate this particular
practice.
And out of that, one of
the things that you're going to develop is your per-visit rate and
that is going to be based on patient encounters. And this is an
area where there's often some confusion in the RHC program. Patient
encounters are face-to-face encounters between the physician, the
PA, the nurse practitioner, certified nurse midwife, or your mental
health providers if you have mental health services in your clinic
and you're going to need to identify all of those encounters by
provider type. You're going to need to also be able to identify
your visits by payer category; i.e., how much - how many visits
did I provide in our clinic that were to patients under Medicare,
how many have provided to patients under Medicaid, how many were
provided to commercially insured, and how many were provided to
self-pay or uninsured.
You'll also need to be
able to calculate your Medicare bad debt. Medicare bad debt is essentially
money that was not collectable from beneficiaries for the Medicare
co-pay or deductible and that can be classified as Medicare bad
debt, which is ultimately reimbursable on your cost report.
Essentially, what this is going to come down to is after you've
gone through pages and pages and pages of accounting information,
a numerical equation in which you have your total allowable costs
in the a numerator, your total allowable visits in the denominator,
and out of that, you're going to get your average cost per visit.
Medicare will pay 80 percent
of the RHC rate - your clinic specific rate up to the cap for independent
RHCs or those provider-based RHCs not operated by a hospital with
fewer than 50 beds. The RHC cap for 2006 is $72.76. So if the equation
- your total allowable costs over total allowable visits - came
out to $80 a visit and you're not a provider-based hospital with
fewer than 50 beds, you're capped at $72.76. But if your rate comes
out below 72.76, then your Medicare payment will be based upon what
your actual cost-per-visit came out to.
You'll receive the RHC
rate for Medicare patients for every Medicare encounter. This is
different than what you would normally see in Part B for a visit.
An encounter is a face-to-face visit between a Medicare beneficiary
and a recognized provider for purposes of the RHC program, which
would be a physician, a PA, a nurse practitioner, certified nurse
midwife, or one of the mental health providers, clinical psychologist,
or a licensed clinical social worker, or Master's degree social
worker for - and I've underlined here - a medically necessary reason.
And that's very important
because very often I'll have people say, well, does that mean as
long as my physician sees the patient everything is going to be
a visit. No because it's not necessary sometimes for that physician
to see a patient for something that does not require the physician's
level of knowledge or expertise. So simply because it may be face-to-face
doesn't meet the test of the visit. It must also be medically necessary.
This very often comes
up in the context of injections - diagnostic tests with regard to
injections. Typically, an injection is not going to be an RHC visit
even though the physician, or PA, or the nurse practitioner may
make that injection because other than certain circumstances, certain
types of injections, it is not required for the physician to provide
that particular service.
In terms of diagnostic
tests, lab and x-ray, the technical component of a lab or an x-ray
is not an RHC service, therefore, it's not billable as a RHC service
but the professional component - the visit that back to the reason
for the lab or the x-ray would be an RHC encounter.
Diabetes education, this
is a relatively new covered service. While the service itself is
covered, it is not - does not constitute an RHC encounter so the
delivery of that service does not count in the - in the numerical
equation in terms of the denominator towards allowable visit but
all of the costs for diabetes education are allowable costs and
go into the numerator of your equation.
Flu and Pneumococcal vaccine
are RHC-covered services but are separately reimbursable on the
cost report and there's a specific place on the cost report to calculate
and identify your cost for the delivery of Flu and Pneumococcal
vaccine.
Visits to the hospital,
a visit to the hospital by the RHC personnel does not constitute
an RHC visit. That is not - so it would not count there. Visits
to a nursing home, skilled nursing facility, or other - a skilled
nursing facility is considered an RHC visit and would be covered
as an RHC encounter, again meeting the test of medical necessity.
Visits to a patient's home to see an RHC patient at the home by
one of your covered providers where medically necessary would also
be an RHC visit.
Now, for nursing homes,
one of the questions comes up, what about swing beds? If it's a
hospital swing bed and that bed at that time is considered a skilled
bed as opposed to an inpatient acute care bed that would be an RHC
visit. It depends on what is the status of that bed at that particular
time.
That concludes the prepared
remarks that I had done. I'll be happy to answer any questions you
may have.
Operator, if you would,
go through the process for them to be able to ask a question. And
I'd just like to remind everyone that during - when you get - your
line is open, please identify by your name and the location - the
city and the state you're calling from.
Operator:
Thank you. The question-and-answer period will
be conducted electronically. To ask a question, please press the
star key followed by the digit one on your touch-tone telephone
at this time. And we will take our first question.
Bill Finerfrock:
Go ahead. Somebody's line's open.
(Dorothy Munce):
Hi. My name is (Dorothy
Munce) from ((inaudible)) and Medical Clinics in Davenport, Washington.
Does
the question regarding swing bed visits being a rural health - can
be billed as a Rural Health Clinic visit? Can that be based on your
FI? Because currently, we are billing those as non-RHC visits because
they are being seen in the hospital versus the skilled nursing facility.
Bill Finerfrock:
Well, remember, that bed at that - once - the
difficulty with the swing bed is that it literally swings back and
forth. Sometimes it's an acute care bed, sometimes it's a skilled
bed depending on the particular situation. When it is defined in
a hospital as being reimbursed for the care provided to an in-patient,
while it is considered an acute care bed, then that would not be
an RHC visit. Once that patient switches over and is now considered
a skilled patient and the hospital is no longer being reimbursed
on the DRG system but rather as a skilled nursing facility services
that then is a rural health clinic visit. So even though the patient
has not moved from the bed, it's determined by how the hospital
is reimbursed for the care being provided. If it's hospital care,
acute care, then it's not a Rural Health Clinic visit. If it's skilled
care, they're being reimbursed for it, it is a Rural Health Clinic
visit.
(Dorothy Munce):
So only if it's a Part A swing bed and not a
- say a Medicaid - where Medicaid is paying the room cost versus
Part A?
Bill Finerfrock:
Well, again, what is the - what is the designation
of the patient at that point? Are they a - are they in skilled care?
Are they still getting acute care hospital . . .
(Dorothy Munce):
No, it would be a swing bed but there is a non-skilled
swing bed and a skilled swing bed. It's just like in long-term care
in the nursing home facility.
Bill Finerfrock:
If it's a non-skilled - if they out of an acute
care bed, whether it's non-skilled or skilled, it is now a Rural
Health Clinic visit. If they're in - if the bed is defined as an
acute care bed, it's not an RHC visit. If it's something other than
an acute care bed, it's an RHC visit.
(Dorothy Munce):
OK. (All right). Thank you.
Bill Finerfrock:
Yes.
Operator:
We'll move to our next question.
(Linda):
Hi. I'm (Linda) from Mark Reed Healthcare Clinic
in McCleary, Washington, and my question is on the Medicare bad
debt, would charity care be considered bad debt?
Bill Finerfrock:
No.
(Linda):
OK.
Bill Finerfrock:
When you provide charity care, you're essentially
saying we have no intention of collecting this money. We're doing
it as part of a charity care policy. Bad debt only applies to that
debt that you are intending and make an effort to seek to collect
but are unable to collect from the patient. So because you define
it as charity care, you have no intention of collecting it, therefore,
it's not bad debt.
(Linda):
OK, thank you.
Operator:
And onto our next question.
(Bonnie):
Hi, Bill . . .
Bill Finerfrock:
Yes.
(Bonnie):
. . . this is (Bonnie) from Great Lakes in Cadillac,
Michigan. I have a couple of questions for you. One is regarding
the medical director. Can we have a contracted medical director
or does it have to be a physician that is actually practicing within
our facility?
Bill Finerfrock:
You need to give me a little bit - in terms of
the contractual relationship it does not have to be an employee,
it can be contracted. But when you're saying the medical director,
what is it that they are doing?
(Bonnie):
Well, currently, we have - one of our physicians
is the medical director of our - of our clinic . . .
Bill Finerfrock:
OK.
(Bonnie):
. . . but we're looking at possibly moving that
position to a contracted physician that would not be actually seeing
patients.
Bill Finerfrock:
OK.
(Bonnie):
And from what I'm seeing here on your presentation,
they need to be seeing patients or be available to see patients.
Bill Finerfrock:
Available to see patients.
(Bonnie):
So clarify that for me.
Bill Finerfrock:
Well, is the medical director ever going to visit
the Rural Health Clinic?
(Bonnie):
Yes, the medical director would be onsite, would
be given direction to the - to the providers here, but not actually
scheduled - our thought was, you know, may not actually be scheduled
to see patients within the clinic.
Bill Finerfrock:
You're going to get some pushback from surveyors.
(Bonnie):
OK.
Bill Finerfrock:
Typically, what it says is that they have to
be available to see patients. Some surveyors are going to want to
see that they are actually scheduled to see patients. I would talk
to your surveyors to see what they would deem to be acceptable,
but technically, the requirement is that they have to be available
to see patients. But I don't believe that there's anywhere that
it says that they actually have to see patients.
(Bonnie):
OK, OK, and the other question comes from the
advisory committee. My understanding of that before was that it
had to just be an outside community member. This is the first time
I've seen where it actually said an outside health practitioner.
Bill Finerfrock:
Well, that's for purposes of the development
of the policy and procedures' manual.
(Bonnie):
Right. We - I mean, we do that but our outside
people are not - are not health practitioners or clinicians. You
know, they are business people within the community.
Bill Finerfrock:
There's two different things here: one is your
advisory board and the other is the development of your policy and
procedures' manual. It's the policy and procedures' manual that
requires that it be reviewed or participation from some other health
professional. Your advisory board, which I didn't get into, does
not - you're not required to have an outside health professional
because one may not exist but you should have your policy and procedures'
manual reviewed by some other health professional to have them take
a look at it.
(Bonnie):
Outside the clinic . . .
Bill Finerfrock:
Yes.
(Bonnie):
. . . and documentation of that.
Bill Finerfrock:
Yes, who did it and when did they do it.
(Bonnie):
Is that new?
Bill Finerfrock:
I don't think so.
(Bonnie):
OK. All right. Thanks very much.
Bill Finerfrock:
Yes.
Operator:
And as a reminder to ask a question, it's star
one on your telephone. We'll move to our next question.
(Phyllis Burke):
Yes, I'm (Phyllis Burke) from South Dakota. I
had a couple of questions here. One is an old question probably
but just wanted some clarification on it and that is the deal with
the lab test for clinic patients in order to get - this would be
a clinic that is connected or a provider-based clinic to a critical
access hospital care so in order to get the cost reimbursement the
patient has to physically walk over to the lab to be drawn in the
hospital. So (if) someone has asked then is there any reason that
if you have your Medicare patients do this that you're non-Medicare
patients could stay in the lab and be billed as a Rural Health Clinic
service versus having them both go over to the hospital?
Bill Finerfrock:
You lost me there. Who is the second group of
patients?
(Phyllis Burke):
Non-Medicare.
Bill Finerfrock:
So we're talking about Medicaid?
(Phyllis Burke):
Or commercial.
Bill Finerfrock:
There's no such thing as a Rural Health Clinic
visit in the commercial world.
(Phyllis Burke):
No, but you'd be doing - you could be doing lab
- you would be doing ancillary, like lab tests.
Bill Finerfrock:
So you're going to - you have a lab in your RHC,
you're going to have your commercially-insured individuals have
the lab - your RHC lab perform the test, but for Medicare patients,
you're having them go over to the critical access hospital's lab?
(Phyllis Burke):
Yes, and the reason that that is being looked
at is because for commercial purposes there would be another deductible
if it's done at the hospital versus the lab - versus the clinic.
Bill Finerfrock:
I don't know the answer to that question. There's
probably a lot of specifics that we don't have time to get into
that may dictate which way the answer would go on that that I don't
have an answer for you.
(Phyllis Burke):
OK, then in regard to a question that was earlier
asked just on that swing bed issue, if the - if the facility has
not done a swing bed visit as a Rural Health Clinic visit can they
go back and re-bill (this)? And if so, how long?
Bill Finerfrock:
Well, you generally have up to a year to submit
a claim for Medicare. So if you feel that you've incorrectly billed
visits that you billed to Part B that should have been billed to
Rural Health Clinic, you'd generally have up to a year to go back
and fix that.
(Phyllis Burke):
OK, now, would (it) make any difference because
the clarification came out saying that this was an allowable way
to do it?
Bill Finerfrock:
Well, it wasn't a clarification; it was a change
in the law.
(Phyllis Burke):
OK.
Bill Finerfrock:
It depends on when you're talking about it. Up
until January 1 of 2005, it was not an RHC visit in the swing bed;
it was only after the law was changed that those became RHC visits.
(Phyllis Burke):
OK, so, basically - OK, I see. OK, thank you.
Bill Finerfrock:
OK.
Operator:
And we'll take our next question.
(Susan Welch):
Bill . . .
Bill Finerfrock:
Yes.
(Susan Welch):
. . . hi, my name's (Susan Welch) from (Nuremberg),
North Carolina. I have a question. We have a physician assistant
that sees rest home patients . . .
Bill Finerfrock:
OK.
(Susan Welch):
... (unskilled) and finds home healthcare plans.
Bill Finerfrock:
OK.
(Susan Welch):
Is that a billable?
Bill Finerfrock:
Well, first of all, it's a test of medical necessity.
If they are - there are a couple of issues here. One is - as presumably
these are all individuals who are patients of the Rural Health Clinic,
you have an established medical record for them and there - if the
PA is simply going to see them in their - where their domicile,
if it's a residential facility or elsewhere other than a skilled
nursing facility, so, as far as that is concerned, it would be.
Now the second question
would be what is it that the PA is actually doing when he or she
goes to see that patient. Is it a medically necessary visit and
without even - I mean, unless you can tell me what they're doing
when they go to see those patients, I can't tell you whether it's
going to be a Rural Health Clinic visit because it's going to hinge
on the test of medical necessity.
(Susan Welch):
OK, I'm not sure what he does either other than
I know he signs home healthcare plans so that they can get home
healthcare.
Bill Finerfrock:
And that's all that he's doing is just simply
going to do a home healthcare plan of care?
(Susan Welch):
My guess is that's probably what he's doing.
I mean, I imagine he's seeing the patient.
Bill Finerfrock:
Yes. I mean, I presume that there's some level
of medical evaluation but I don't know how often the plan of care
- plans of care need to be updated. I would - who's your - you're
in North Carolina?
(Susan Welch):
Yes.
Bill Finerfrock:
Is it - are you - are you provider-based or independent?
(Susan Welch):
Provider.
Bill Finerfrock:
I would check with your provider - Fiscal Intermediary
to see what they do or also get more information from your PA as
to exactly what's going on during the encounter.
(Susan Welch):
OK, so (if) it's medically necessary, though,
and . . .
Bill Finerfrock:
Medically necessary. If it meets the test of
medically necessary, then it would - you know, the location is an
acceptable location and provides Rural Health Clinic service.
(Susan Welch):
And the location would be a revenue code ((inaudible)).
Bill Finerfrock:
Well, there are new revenue codes. I don't have
them here in front of me. We've sent them out. They've created several
new revenue codes, of which one is a domiciliary care facility and
it sounds like you would use that revenue code.
(Susan Welch):
OK. All right. Thanks.
Bill Finerfrock:
Yes.
Operator:
And moving onto our next question.
(Kelly Ann):
Hi. This is (Kelly Ann) from (Penora), the (Penora)
Medical Clinic, and my question is the outside source that needs
to help with the policy and procedures' manual can that be from
the owner of the RHC - (like run) by a hospital?
Bill Finerfrock:
You mean a nurse or a - some other health professional
at the hospital?
(Kelly Ann):
Yes.
Bill Finerfrock:
Yes, that would be fine.
(Kelly Ann):
OK, I just didn't if they needed to be somewhere
outside of the owner. OK, thank you.
Operator:
And our next question.
Bill Finerfrock:
I think is going to have to be the last question,
Operator. I think we're up on our hour.
(Carrie):
This is (Carrie) at Triangle Healthcare
Bill Finerfrock:
OK.
(Carrie):
I have two quick questions.
Bill Finerfrock:
((inaudible)) from (Carrie)?
(Carrie):
Triangle Healthcare in Chester, Montana.
Bill Finerfrock:
OK.
(Carrie):
In regards to safeguarding against destruction
of charts . . .
Bill Finerfrock:
Yes.
(Carrie):
... can you have open shelving system or do you
have to have a file system like open shelving?
Bill Finerfrock:
Is there no - there are no doors on the shelves?
(Carrie):
No, it would be open shelving.
Bill Finerfrock:
Is the - is the - is it in a room that is - that
can be locked?
(Carrie):
It could be, yes.
Bill Finerfrock:
This is an area where there's been different
interpretations by surveyors. We had a clinic a few years ago that
had an open shelving system in which the surveyor came in and told
them they would have to put in locking cabinet doors on the shelving.
We were able to get (it) that that was OK as long as it was in a
locked room, that the - that the shelves themselves did not have
to be locked as long as the room could be made secure. So it should
be sufficient.
Have you been surveyed and has there been a question raised about
that?
(Carrie):
No, we're an existing provider-based RHC and
we're looking at the possibility of changing from file cabinets
to open shelving so I just wanted to check into it before we went
to the expense.
Bill Finerfrock:
Yes, it's - I mean, I would - I would encourage
you to contact your surveyors to make sure that they have not -
they don't have a problem with it. As I've said several times, there's
a subjective component to this where you're dealing with individuals
who are making interpretations. We have gotten it, that open shelving
is permissible as long as the room can be locked and made secure.
(Carrie):
OK and just another really quick question on
the cost report. We're a provider-based owned by a hospital.
Bill Finerfrock:
OK.
(Carrie):
Right now we keep all the physicians' compensation
in the RHC and what is your feeling about moving some of those costs
based on percentages from the time studies to like the hospital
ER or nursing home?
Bill Finerfrock:
So - I probably can't give you an opinion because
it's probably too complicated but - so right now all of your compensation
for the physician is appearing in your RHC cost report regardless
of whether they're seeing patients there or not?
(Carrie):
Correct.
Bill Finerfrock:
I would think you'd want to look at that because
I think you might run into - are you - did you say you're a critical
access hospital?
(Carrie):
Yes, we are.
Bill Finerfrock:
So you bill (at) 50 beds?
(Carrie):
Pardon me?
Bill Finerfrock:
There are fewer than 50 beds.
(Carrie):
Yes.
Bill Finerfrock:
So you're exempt from the cap. You might run
into a question of reasonableness, that if that physician is not
spending all of that time in the RHC and those costs should be allocated
elsewhere that the (physical) intermediary would question those.
(Carrie):
OK.
Bill Finerfrock:
All right?
(Carrie):
Thank you.
Bill Finerfrock:
I think that's going to have to do it for today's
call. I want to thank everybody for all of the great questions and
your participation. I also want to thank the Office of Rural Health
Policy for their generous support of this series.
A transcript from today's
call will be available in a few weeks and it'll be posted on the
RHP Web site and we will get notification of that out through the
list serve. The next conference call will be announced shortly and
you will receive an e-mail notice of the date and topic and time
of that next call.
I want to encourage you
to let others know about this series. I encourage them to register
and participate. As you heard today, we have folks from literally
one side of the country to the other participating. This has been
a great forum process to get people and get some of these questions
out there. And if you have suggestions on future topics, please
don't hesitate to send them to me at info@narhc.org.
So thank you again for
your participation. We look forward to talking to you again.
Operator:
Once again, that does conclude today's conference
call. We thank you for your participation and have a great day.
END
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