Operator:
Good day everyone and welcome to today's RHC
Technical Assistant conference call. Just as a reminder, today's
call is being recorded.
And now for opening remarks and introductions,
I would like to turn the call over to your host, Mr. Bill Finerfrock.
Bill Finerfrock:
Thank you, operator. Welcome everybody to this
the twelfth Rural Health Clinic Technical Assistants conference
call. Our topic today is what are billable, allowable and covered
charges in the RHC and our speaker is Linda Dartt.
I'd like to welcome everybody and point out that
I am the Executive Director of the National Association of Rural
Health Clinics.
Our call today - this series of programs is sponsored
by the Office of Rural Health Policy and we want to thank them for
their support of this initiative.
Our speaker today, as I said, is Linda Dartt.
Linda is a Health Care Consultant who lives in Montville, Maine.
She's done a considerable amount of Rural Health consulting; she
provides consulting on business issues and assistance with applications
for Rural Health Clinics and works with other types of health centers.
Linda was previously a consultant at an internationally-recognized
firm and has held several positions with Maine health care providers
of various types. She moved to Maine in 1980 and completed her BS
Degree at the University of Maine and she has worked in the health
care field for more than twenty years.
Today's program is scheduled for one hour; the
first 45 minutes will consist of Linda's presentation with the remaining
time for questions and answers. This call series, as I said, is
sponsored by the Health Resources and Service Administration, Federal
Office of Rural Policy in conjunction with the National Association
of Rural Health Clinics.
The purpose of the call is to provide Rural Heath
Clinic staff with technical assistance and RHC specific information.
Today's call is the twelfth in a series that we began in 2005. I
am pleased to report that we were recently awarded a new five year
contract by the office of Rural Health Policy to continue this series
for the next five years and we're very pleased to be able to announce
that this series will be continuing. The initial contract was for
two years, so we've got a new lease on life with this initiative
for five more years.
Please join me in welcoming now our speaker,
Linda Dartt, who is going to talk to us about billable, allowable
and covered charges in the Rural Health Clinic, Linda.
Linda Dartt: Thank you, Bill, and welcome everyone.
It's a beautiful sunny day here in Maine in the seventies. I hope
it's nice where you are.
We're going to try to get through the basic concepts
of the three areas of Medicare and Medicaid coverage that I consider
really important conceptually. After today, you should be able to
go on and figure out your details and put your specific questions
at least into an area so you can frame them with payers or with
your government representatives. Anyway, the goals today are for
you to understand what is a covered service, what allowable means
in an RHC -- what is the difference between those terms and, beyond
the questions of covered and allowable, what are billable services.
All of these terms mean different things for Medicare and Medicaid
and they mean different things for those two payers than they do
for everybody else.
I would suggest at this point, if you would like,
you could remove the last three pages of your slide copies, that
have acronyms used in this presentation, just in case I fall into
using the acronyms. I'll try not to, I'll try to say the whole thing
out, but just in case, you might put those pages aside so you'll
have them for reference.
So starting with what are Medicare covered services
because that's kind of the Core of the RHC provider type that was
created as a Medicare provider-type and, because RHC is a provider-type,
you have to remember that Medicare covered services will vary by
the kind of institution that you are. I call the provider types
"institutional" provider-types, but that's not an official
term. You can be an RHC; you can be within that, an I-RHC (Independent
RHC) or a PB-RHC (Provider-based RHC). If your clinic is provider-based,
with a CAH (critical access hospital) as your parent provider, covered
services may be handled, and some will be billed differently, from
the way an I-RHC handles the same type of service. A PB-RHC with
a large hospital system as its parent will have to live within the
federal per visit cap; a PB-RHC that has a small rural hospital
with less than 50 beds as its parent does not have a per-visit payment
amount limit (cap). Among the Medicare provider types, there are
CHCs (community health centers), FQHCs (federally qualified health
center) look-alikes, there are hospitals and CAHs, there are outpatient
departments, ambulatory surgical centers and the list goes on and
on and all of those entities have different sets of covered services.
All of these differences define what your covered services will
be and how you will deal with some services such as billing for
lab tests.
So you have to know what your provider type is
- RHC, but you also need to understand the permutations within RHC
when you're applying these concepts.
To further complicate our ability to understand,
the basic Medicare covered services also vary by the kind of individual
who is providing the service. So if a doctor, an MD or DO, provides
the service, it may still not be covered because it's, for example,
a mental health service that that particular doctor is not qualified
to deliver. You always have to remember that providers (and other
staff when applicable) have to be working within the rules that
cover their licenses and your state regulations and their entity
type as well. These elements form a kind of matrix that affects
what's covered in any specific situation.
Coverage can also depend on the diagnosis. I
remember when podiatry first became a big deal in Rural Health Clinics
-- the only times we could get podiatry services covered were if
the patient was diabetic. I think it has loosened up a bit since
then but it's still pretty hard to get paid for podiatry services
in an RHC, even though the State probably classifies Podiatrists
as Medical and/or Osteopathic Doctors. So you've got to know how
the patient's diagnosis drives what's covered and who can deliver
the services for that diagnosis and then it also matters whether
you are delivering the service in your office, at the patient's
home, at the hospital or at somebody else's practice. There are
a lot of places that you can deliver these services.
One of the things that I like to use as an illustration
is the situation of a registered nurse. There are registered nurses
all over the country, working in all kinds of health care settings.
When they work in Rural Health Clinics, you are always told by government
payers that nursing services are covered. Nursing services
are covered. That does not mean that you can bill for an RN. It
doesn't mean that everything that they do is going to be allowable,
which we'll get to later. It doesn't mean the doctor can send the
RN over to a Senior Center to do blood pressure checks and have
it covered. But that RN can perform Nursing duties in the Rural
Health Clinic, up to the limits of State RN licensure, and the cost
of having Nurses is included on your cost report. The Nursing costs
then go into setting your RHC payment rate, which is really the
average cost of delivering a visit to the average patient. So it's
included, it's a cost for covered services. However, when an RN
who has been working, for example, in a Home Health Agency and who
could do things on her own judgment (within a doctor's Plan of Care)
out in the patient's home becomes a Nurse in an RHC, he or she cannot
perform the same tasks, and the RHC cannot bill Medicare, because
Nursing is not a billable service in an RHC
The reason that I use a Home Health Nurse as an
example is that you will read in the regulations that an RHC Nurse
can deliver services in a patient's home, without direct supervision
(if State law allows) in a home health shortage area. An
HHSA (Home Health Shortage Area) designation requires approval from
HHS (Health and Human Services) and is a very difficult designation
to obtain. The regulations do not mean that you can decide to send
your Nurse over to a patient's house to do something because you
perceive a shortage and it is something he or she can do within
the RHC.
Anyway, sometimes you find Home Health Nurses
moving from Home Health or hospitals into the RHC environment and
the nurses really believe that they can do all the things that they
did as a Home Health or Hospital Nurse. Well, they can't, even though
it seems entirely logical that they could. Their licensure hasn't
changed, but their set of covered services has changed because they
are working in a different kind of entity and where they're delivering
the services matters for Medicare.
You have to be really careful about what your
definitions are, and it's really important when you're talking to
your payers, your state regulators, federal representatives and
government employees because they are very used to figuring out
the fine lines between covered and non-covered, between hospital
based RHC and Independent RHC and if you call something by the wrong
name or ask a question that is not carefully worded to communicate
your meaning - You may get an entirely wrong answer that the person
who delivered it thought was exactly right for your situation, but
it isn't because you're not applying it the way they meant. Don't
be afraid to tell them what you want to do and ask for their
guidance. Often, just making a slight change in your plans will
satisfy both the RHCs needs and the patient's needs as well as remaining
on the right side of the regulations.
So you move from the general concept of covered
Medicare services to really the heart of what Rural Health Clinics
want to know, which is "What is covered in my Rural Health
Clinic?" And again, the answer to that is set by Medicare after
our legislators make laws about government-managed health care services.
Medicare decided what the RHC Core services would be and they are
the ones that the original program was meant to deliver. The kind
of family practice, small rural doctor's office that was out there
struggling had a set of Core services that were commonly provided.
The regulators at Medicare decided that this model would guide what
was to be covered as RHC Medicare-covered services. As coverage
expanded, optional services were added and those original RHC services
became known as "Core" services.
Medicaid came along later and the federal Medicaid
regulations required State Medicaid Plans to include those RHC Core
services - the ones covered for Medicare beneficiaries - in their
Medicaid RHC programs. However, because Medicaid is a state-operated
program, funded by both federal and state governments, other services,
supplies, sites, etc. may be included in a State Medicaid Plan.
Here in Maine, RHC services include those of licensed substance
abuse counselors and licensed professional counselors. This is very
convenient for RHCs here, but it doesn't mean that a Rural Health
Clinic in Vermont can bill for their licensed substance abuse counselors
or their licensed professional counselors, because these are licensure
types that are controlled by the states. It also does not mean that
an RHC in Maine can consider the services of a LSAC or LPC covered
for Medicare patients because Medicare doesn't see them as RHC providers.
Here in Maine, at one point in the development
of the RHC program, we had licensed pastoral counselors being covered
because there was a typo in the regulations. It was supposed to
be professional, but pastoral got into the new Manual and Pastoral
Counselors came out of the woodwork to bill Medicaid so they changed
it. My point is that Medicaid coverage is very different from state
to state. There is this basic center Core of services that they
are required to cover, but everything else is optional and that's
why they're called - Optional Services. I always think of Bill's
answer to one of the questions that was asked on the list server
one time, "Can I hire some kind of unusual provider in my RHC?"
The provider was a type that was not customary in a Physician's
office and the answer was, "You can hire anybody you want."
He went on to say that the question should be whether the services
are covered, whether the cost is allowable on your cost report and
whether you can actually bill for it, all of which makes a huge
difference.
The Medicare Core services definition - the basic
set of RHC services - arose from the historical goals for the program,
which were to deliver primary preventive care in rural area that
had consistently, and over long periods of time, had trouble recruiting
doctors and when they did recruit them, and this is still true in
some areas, they would quickly burn out because they were the only
doctor for many miles around and people were calling them 24 hours
a day. So this was a program that was meant - one of its major goals
was - to alleviate this persistent recruiting and retention problem
in rural areas.
One of the ways that the government decided to
address the problems was to create the RHC Program through Medicare.
The RHC Program offered the practice higher payments from Medicare
as an incentive for PAs (Physician Assistants) and NPs (Nurse Practitioners)
to practice in rural areas. The practice also received higher payments
for those PA and NP services than they would have previously. Assuming
that PAs and NPs would have lower salaries than Physicians, costs
would go down.
There was a complicating factor at the time that
had to be addressed so they had to go back to the law, not just
the regulations, because PAs and NPs, at that time, were only allowed
to provide services to Medicare patients when the Physician was
in the building with them. This was kind of difficult to implement,
especially in rural areas. If a doctor wanted to have PA or a NP
working with them in the practice, the doctor still had to be there,
so you had to have enough patients to require two practitioners
and in many places, they could hardly support one. So Medicare changed
the rules and said, if you pass the tests and become a Rural Health
Clinic, then your PAs and NPs can bill Medicare and get paid at
the same rate that Medicare would have paid had a Physician delivered
the services and the Physician does not have to be in the building
while they deliver it.
It took a while for some of the states to catch
up with this and they went through a phase at one point, where several
states said that the Physician had to be in constant telecommunications
contact with the PA or NP. That's kind of gone away too. The RHC
regulations require that all of the current non-Physician providers
be under supervision and compliant with state law. The federal regulations
are silent on how that supervision is to be carried out because
that is a power left to the states, and in many, supervision rules
today are very loose. Here in Maine and several other states, Nurse
Practitioners have independent practice status and can provide services
without supervision, but we still have to explain to NPs who work
in our Rural Health Clinics that they have to be under the supervision
of a Physician when working at an RHC. As an additional comment,
Physicians working in an RHC are required to be following the clinical
policies as set by the Medical Director, which is very different
from the usual arrangement at a group practice. In return, all providers
should have input into those policies. The Medical Director and
a non-Physician practitioner are required members to be included
on the Policy Review/Policy Manual Team.
This ability to bill Medicare and later Medicaid
was a great boon at the time that it happened in the late '70s.
Physicians at that time sometimes had two or three clinics for which
they were providing Medical Direction, with PAs and NPs delivering
most of the services. The RHC Act provided an enhanced environment
for PAs and NPs and allowed Physicians in some rural areas to improve
access for patients because they no longer had to do over-the-shoulder
supervision. Physicians were able to do hospital and nursing home
rounds, see contagious patients at home, and concentrate on services
that actually required a Physician. By the way, in the'70s before
the Rural Health Clinic Act was passed, the payment the PAs and
NPs received even when they provided services in the same building
as the Physicians was less than 100% of what the Physician would
have received. I think it was about 80 percent originally and has
changed since then. It just didn't make sense for most rural areas
to use these new care extenders that were being trained, providers
who were able to provide most of the services the Physician could
provide but the practice couldn't get paid appropriately by government
payers if a NP or PA delivered the service. The Physician Extenders
were out there anyway and they were employed in various settings.
Sometimes, they were being paid through state or private grant programs.
We had visiting nurses in Kentucky and other places mostly in the
Southeast; they had Medicare patients, but they couldn't bill Medicare.
So somebody else had to pick up the cost, and it was a very different
situation from one state to the other.
But with the RHC Act, we now had RHCs in areas
that had a Physician only when needed and for the required oversight
and services. Maybe a private Physician in a town a hundred miles
away from the RHC would agree to come once a week or once every
two weeks as minimally required. The RHC had to be in an HHS approved
shortage area to do this, which meant that you had to prove your
area was medically underserved or that it was short of primary care
health professionals. That's still true and shortage area designation
is an interesting topic for another time.
There are tricks to being able to successfully
apply for a shortage area that are learned over time. Sometimes,
it is more an art, requiring not just an understanding of the of
the federal requirements, but creativity and determination The service
area, the people served or to be served, the existing conditions
applicable to the goals you have all have to be put together in
a meaningful way that provides the required documentation to result
in a successful designation. This process requires knowledge of
the service area, demographic research and sometimes assistance
from the Primary Care Association or the State Primary Care Office.
The RHC program allows RHCs to receive interim
payments, at the average cost to the practice to deliver a visit
to a patient of any type. This is the averaging concept that's behind
Rural Health Clinics. It's a very hard concept for people who have
worked in other parts of healthcare to understand. It's not normal
for a Physician's office to get the same payment base for all of
their government-paid visits, to get a per visit rate instead of
being paid for each service separately. In the rest of the healthcare
world, the focus is on documenting elements to receive appropriate
reimbursement. Now, the hospitals have changed a little bit since
the DRGs (Diagnosis Related Groups) but until the 1990s, it was
one code per procedure, with a fee for each and if the claim did
not accurately report all of the services delivered, there was no
payment for that item.
Bill Finerfrock:
I'm sorry, Linda, can you alert the listeners
as to what slide you're on?
Linda Dartt:
I am currently on slide seven. Sorry, I do tend
to ramble.
Bill Finerfrock:
That's all right, so that they can help follow
along. Thank you.
Linda Dartt:
OK. I'm currently on slide seven and I'll try
to stay with the slides and tell you where I am.
Part of the RHC Act says that if we are going
to give you this rate incentive, this wonderful boon in your payments
-- the original RHC payment was $25 per visit -- we're going to
make you jump over a lot of hurdles, just like the federal government
always does. When they give you something, they always want you
to assure things in return.
So the predecessor agency to CMS (The Centers
for Medicare and Medicaid Services) came up with a set of rules
that said you have to do some things to deserve the higher payments
and more flexibility in employing PAs and NPs. You have to be handicapped
accessible. You have to assure us that you are providing high quality
care at a facility that is safe for Medicare patients. You have
to have a policy manual that is developed by a team of professionals,
including at least one MLP (mid level provider/NP, PA or CNM currently),
the Medical Director and someone from outside the RHC. The details
are things like having written patient records and signs for exits.
You have to have a Physician who's your Medical Director. You have
to have a PA or a NP - originally 60% - it's now 50% of the time
of the time that you are open to see patients. That was to assure
that these new PAs and NPs who were being trained would have work
to go to in Rural Health Clinics and it still is a very - it's a
high level of care that you are required to provide. Anybody who
works in the private practice world knows that there are a lot of
rules in those interpretive guidelines and in the survey documents
that the surveyors use when they come to visit you that private
practices don't pay any attention to at all, but you have to and
in return you get a higher average payment from Medicare and Medicaid.
I call it "ownership of the patient" in terms of being
able to track who your patients are and how you have treated them,
etc.
You will also hear the Rural Health Clinic Act
sometimes referred to as Public Law 95210. And that's what defines
the Core services, I'm on eight here, to be services of primary
care Physicians, NPs and PAs. Primary care Physicians for this new
program were defined as family Practice, General Internal Medicine,
General Practice, Ob/Gyn and Pediatrics. In addition, any services
incident to those professional services, which is how things like
bandages - incidental services and supplies got included. The asterisk
at the bottom of Slide 8 explains incidental. These are things that
are not chargeable but they are included in your cost when you build
a cost report so they're part of your average cost of delivering
a visit. Obviously you don't use bandages or you don't use a dressing
at every visit, but you do use them at times, so it's just averaged
out.
This program was really simple to begin with.
We all had a concept of visits, coding was no where near as advanced
as it is today either on the diagnosis or on the procedure level
and we really had a mentality that said we deliver a visit (face
to face, medical necessity, entry in record), we bill for it. But
now, today, you compete with different kinds of entities in your
home markets and you have to deliver a lot of those ancillary and
specialized services in order to stay in business. They have to
be convenient for the patient. The RHC program has evolved over
time and it will continue to evolve into the future and, hopefully,
we'll have some impact, through NARHC (National Association of RHCs)
and other groups, on how it evolves. Some of those extra services
or things that are not recognized currently, especially the new
special drugs, the cancer drugs and that kind of thing that Bill
and I were talking about earlier, that have appeared in the last
few years, are very expensive to buy and including them on your
cost report is not really the answer to how you get reimbursed because
of the cash flow issues. When you spend $300 or $400 for a supply
of an injectable drug, you need to recover the expense soon, not
after you submit and have settled a cost report, which can be months
after the fiscal year end.
The other thing that the Rural Health Clinic
law said was required and it still says this, is that the practice,
the Rural Health Clinic practice that was converting needed to be
"primarily engaged" in the delivery of primary care and
this is very vague. I don't know whether primarily engaged means
more than 50 percent or more than 75 percent. Typically it has been
somewhere in that range when the question has come up but still,
you cannot be a specialized practice that does a little preventive
care on the side and be an RHC. You won't be certified or you shouldn't
be certified because you're not fulfilling the intents of this program.
So primary care is the focus. Where it will go in the future, I
don't know.
The Rural Health Clinic program requires that
the provider, the actual Physician, a PA or nurse practitioner and
then a little later, certified nurse mid-wives got added, had to
come face-to-face with that Medicare patient. They couldn't be talking
to them on the phone, they couldn't be sending messages over a computer,
they had to be face-to-face with the Medicare beneficiary and talking
about something.
There had to be medically necessary reason for
that face-to-face encounter to occur and this is still a big issue
that I see in the list serve is just because your Physician had
a visit with a patient doesn't mean that it's covered because they
had to have a reason - a medical reason - to have that visit. If
the patient just came in and chatted or got something they could've
gotten somewhere else not from a Physician, then it's not covered.
It has to be medically necessary to be a visit and originally it
was - again, it was very easy to deal with these situations where
you had one patient on one day. I used to tell computer vendors
all the time, break the record on patient name and date, that's
all I want. I want everything that happens to a patient on one date,
on one day, to be collected together in my bill. Even lab work was
originally rolled into the visit claim. There was no incentive to
provide additional tests for the convenience of the patients because
no matter how many labs tests were done, the payment was the visit
rate. Today, RHCs often have many non-covered services and deciding
whether to carve them out on the cost report or keep them separated
in the delivery area can require a complex analysis.
We used to be able to write on the bottom of
our claims before they went out when a patient had a second visit.
An example that Medicare or Medicaid would always give us was, we
had a pregnant woman who came in for a regular pre-natal visit in
the morning and then sometime later went home and pounded her thumb
with a hammer or something and that visit was OK if that patient
came back to the RHC, they could get paid for that visit again because
it was a different reason, it was a different diagnosis that brought
them in but these were so unusual that we would just literally write
by hand on the bottom of the claim what happened, why we gave a
second visit to this patient on that same day and they would get
paid. Now nobody looks at them and nobody writes on them because
they are all electronic or mostly electronic. So, you have an issue
with documenting the necessity for the second visit prior to sending
it in.
The other thing in the beginning was that what
Rural Health Clinics did really didn't matter a whole lot to Medicare.
From fifteen to twenty years ago when I would talk to Medicare provider
representatives, they would say, look there are twelve of you in
the state. We don't really care. You are not processing enough money
for us to really care, just send in your visits and we'll pay for
them. They didn't care what the charges were, what the code was,
if there is a diagnosis code on there, they would just pay them.
And obviously, that's become much more technical today. You need
to be very careful, very accurate about what you're billing for,
what you're providing in your Rural Health Clinic.
Bill Finerfrock:
Linda, just to give you a time check, we have
about twenty minutes before we go to Q and A.
Linda Dartt:
Great and that's just about right. So anyway,
I'm just trying to tell you that you have a much harder job today
and that's why I think it's really important to understand the basic
concept and also, what I said for a very long time and when I managed
practices I had a requirement that every new employee read the Rural
Health Clinic manual and I meant read it, not just scan through
it. Providers did it, billers did it, administrators did it, everybody
did it and we discussed it at staff meetings because the RHC program
is built on a difficult concept to understand. It's so simple that
those of us who work in healthcare don't believe it can be true.
But it's evolving, as I said, and you're hanging
a lot of extra things off the edges of these RHCs and we just have
to figure out how we're going to address how to handle them in the
future. There are now, I don't know, Bill can tell you, more than
3,000 of you out there and you can have a lot to say about where
this program goes in the future by working through the national
association and by working through your representatives. And that's
my little push for being active.
Anyway, through the amendments over the years
- I'm on slide ten, through the amendments over the years, the Medicare
program added CNMs (certified nurse-midwives) and CPs (clinical
psychologists) and LCSWs (licensed clinical social workers). Mental
Health is another area where there is a lot of confusion but this
is not any social worker that you can hire. This is not the people
who come to you and say that I'm a Masters level social worker,
that's nice but they need to have the clinical experience and it's
very explicitly described how much clinical experience each of these
types have to have before they can be a Rural Health Clinic provider,
an official provider. But they made the incident two services of
course, and it goes on every year, year after year, things get clarified
and unclarified and added to and undone and you just need to pay
attention to where it's going and you need to read your Rural Health
Clinic manual again every once in a while and just check on what's
different. For instance, it looks like RHCs should be planning and
developing a formal Quality Assurance Plan as it appears that will
be part of the new regulations expected in 2007.
So the current definition is Physician services
and the Physician has to deliver primary care; he or she has to
see patients. Your Medical Director has to deliver some services,
serve as the clinical leader for the practice, assist in developing
the policy manual, and develop, along with your other providers,
clinical policies for the RHC. A Medical Director doesn't sit in
a room and write out clinical policies, he or she will work with
the other staff members, consult practice guideline sources and
come up with appropriate policy for the practice. The Medical Director
has to provide whatever supervision of other staff that your state
requires and also see some patients.
The federal government says in the Rural Health
Clinic program that the MLPs - PAs, NPs and CNMs have to be under
the supervision of a Physician in a Rural Health Clinic. I have
to address this disparity in the regulations in Maine because we
were employing NPs who had met the requirement for and declared
Independent Practice. They had worked or were still working elsewhere
without any required supervision. They have been out there practicing
on their own and then they come to work in a Rural Health Clinic
part-time and they think they are still working on their own, but
they're not. They're working under the supervision of a Physician
and they are required to follow the policies in the RHC Policy Manual
for the practice.
So now we have the PAs, NPs, CNMs, CPs and LCSWs
and their supplies and services covered.
We also have the issue I talked about before,
there is in the Rural Health Clinic regulations a little note that
says that Rural Health Clinics can provide visiting nurse services,
meaning to homebound patients. Home health services in a home health
shortage area and that means an area that has applied for and been
granted a fairly recent shortage designation for home health not
for any other purpose, not for mental health, not for RHC, not for
being a rural health - a federally qualified health center, nothing.
It has to be a home health shortage area and I have personally tried
to establish a couple of these and our home health agency are very
powerful and they do not want this to happen so you just have to
remember that maybe you've got a case out there but it's a difficult
one to make and you've got to get over the hurdles if you want your
nurse out delivering services to homebound patients. I would suggest
that you get together with a home health agency and work out a deal
with them to get those patients taken care of.
Additionally, for CPs and LCSWs, there are mental
health coverage limitations in Medicare and they apply to these
providers whether you are in an RHC or not. They don't apply the
limits to the charge, they apply them to the rate when it's paid,
but it's still limited and you end with about 62 percent, I believe,
of your rate from Medicare.
You can provide these Core services pretty much
anywhere except in a hospital. If you go in to see a patient in
a hospital, you've got a patient admitted whom you see as an inpatient,
your visit to that patient is not a Rural Health Clinic visit, it's
a part B service. The payer is the Medicare Fiscal Intermediary
for PB-RHCs and Part B carrier for I-RHCs. For Medicaid, I don't
know how many different ways I can tell people that Medicaid is
a state-specific program. There are federal regulations but the
regulations that apply to Rural Health Clinics are about those Core
services.
The other services that your state decides to
put in its Medicaid Program are to a great extent up to the state,
as well as how they pay for them and how many visits a patient can
have. You can sometimes win battles. I won one with Alabama over
a limit of ten RHC visits for pregnant women with Medicaid at one
point, but sometimes you can't. Your state is driving what these
covered services are and there are forces that are not apparent.
The services are optional and if it's not covered by a Medicaid
program, it doesn't matter, then it's not going to be an allowable
cost and you're not going to be able to bill for it and even if
it is covered, they set their own billing policy. Most states use
HCFA 1500s rather than the UB92 used by Medicare. Each state has
its own, very detailed, state program. Your should make friends
with your state's Medicaid employees and find out how they're implementing
Rural Health Clinic, and if you don't think it's right, you need
to talk to NARHC or to somebody higher up or whatever, but you need
to be contacting them and keeping track of what's going on in your
Medicaid program because it changes a lot faster than Medicare does.
Then to allowable, allowable has nothing to do
with your everyday practice. It has nothing to do with what you're
doing on the frontline with your patients. It's a cost reporting
term. Essentially what's allowable are any costs that were associated
with delivering covered RHC services. What is billable as an RHC
encounter is part of the formula for deciding what your average
cost per visit is. Your allowable cost, as defined by Medicare,
is the numerator of an equation and the number of billable RHC visits
is the denominator. When the total allowable costs are divided
by the number of total visits, the result is the average
cost of each visit delivered. An allowable cost will result from
providing covered services, but that cost did not necessarily generate
a billable visit.
There are regulations saying that allowable cost
has to be reasonable; you can't charge anything you want and expect
the patient to pay 20%. Medicare now has reasonable amounts for
things through their RBRVS schedule. You can now go on line and
see how much Medicare thinks is the appropriate payment for any
service they cover. Previously, the fee schedules of comparable
practices used to have a lot more impact on the allowable and reasonable
test. Now, the situation is reversed, most practices use the Medicare
definitions of what is reasonable to include in charges as part
of their charge building process, not only because it is easy to
update fee schedules when changes in coverage occur, but also assures
that they are charging at least as much as Medicare will allow,
but not so much more that it becomes unreasonable.
Next, allowable costs must be necessary. You can't
just decide to have some service on the side because it would be
convenient for you. It has to be necessary to efficiently deliver
covered services.
You can include your direct costs - that would
be things like pay for the people who work for you, the supplies
that you use that you haven't charged for, all those things that
you use to provide covered services. You can also allocate a piece
of your overhead, your administrative costs, whatever applies to
your Rural Health Clinic and again back to the beginning of the
RHC Program, almost everything applied then. When we filled out
an RHC cost report twenty years ago, it was pretty simple. Every
expense we put on the cost report, with very minor and uncommon
exceptions, was allowable because we weren't doing anything that
wasn't covered. So again we had it pretty easy then; you don't now.
Today, as I said earlier, you have more competition and higher patient
expectations for what should be offered in a rural practice. When
this program began, just being able to support a rural practice
was enough incentive to stay within the regulations.
However, the more of these "specialty"
and ancillary services you offer on the side, the more difficult
you make your cost reporting for yourself. Sometimes, the other
benefits of offering a new service can outweigh the additional complications
of keeping non-RHC costs separate from your RHC allowable costs.
There are wonderful resources out there to use in your planning;
for the decision about a new service, I would start with www.Medicare.gov.
In fact, it is probably a good idea to explore the Medicare web
site and its educational resources. The have manuals, there's an
address on slide 14 where you can go to pick up the actual manuals
from Medicare, at Health and Human Services, CMS (The Center for
Medicare and Medicaid Services). Again, your allowables are going
to vary by institutional provider types. If you're a home health
agency, you can include allowable costs for physical therapy. If
you're Rural Health Clinic, you probably can't unless you want to
hire a Physical Therapist to provide visits you can't bill. Although
that would probably be justified as allowable in certain cases,
your average cost per visit would be exorbitant. I expect that even
a PB-RHC without a cap (rural, < 50 beds) would have difficulty
justifying including the service. PT is just not a Rural Health
Clinic service. Even if a Physician delivered it, it wouldn't be
billable or allowable because the Physician is probably not a Physical
Therapist and it's not considered part of primary care. A Physical
Therapist is not a billable provider or a normal clinical support
person in a doctor's office. All of this could change of course,
as the population ages more people may need Physical Therapy or
other supportive services and they may become common in doctor's
offices.
Back to the RHC/FRHC Manual, please read it.
That is the basic set of rules for RHCs. Pay attention to it, ask
Medicare representatives questions about it. Find somebody who really
knows the answers and ask them, not a friend, somebody who works
for Medicaid, if you want answers about Medicaid and someone from
Medicare or the Medicare web site if that's what you need to know.
Go to NARHC because it is an organization devoted to supporting
this program and helping it evolve appropriately for changing times.
Again your Medicaid allowable costs are going
to follow whatever the covered services are in your state Medicaid
Plan, what they allow you to bill for, how many Medicaid-covered
patients you have. The billing methodology can be very different
from Medicare. You have co-payments in some states, minimum spending
amounts in some states, even deductibles for Medicaid patients,
but some states don't have any of these things. You just need to
know what your state is doing. Get a copy of your state's Rural
Health Clinic manual section or separate manual, whatever it is.
Get a copy of it and read that too.
Non-allowable costs - I'm on slide 16 - non-allowable
costs include the direct costs to deliver non-covered services,
so if you're doing something that isn't listed under those covered
services, you have to separate out whatever the direct costs are,
and there is an example at the bottom of Slide 16 that we'll use
to explain how to do that. You have to use those direct costs to
pull out (e.g. re-allocate) a percentage of your general costs --
receptionists, billers, bookkeepers, electricity, office cleaners,
managers and other clinical and administrative support people. The
way you do it, and please, don't go to sleep here because you don't
like math. This is important and it's not difficult once you get
the hang of it. It's the basic concept behind identifying the cost
of allowable and non-allowable services. If you understand this
underlying equation, you understand a big piece of cost reporting.
You will better understand the concerns of the people who concentrate
on finance at your RHC. When they are very worried about what you're
doing in your Rural Health Clinic and whether it's an RHC covered
service, whether it's going to be billable, whether it's going to
be allowable, you will be able to explain better the other factors
to be weighed against financial advantage and disadvantage. They
need to know these things in order to incorporate expected revenue
and cash timing into budgets and reports. If you understand this
basic algorithm, you will go a long way to understanding why they
need to know these things.
In order to identify your non-allowable costs,
your direct non-covered costs (salaries for providers and/or support
staff who are exclusively devoted to that service, or the identifiable
portion of their total devoted to it; if there are special supplies
for the service, the actual cost of supplies used to deliver that
kind of service; licensing fees directly attributable to non-covered
services and add them up. Then you add all your direct covered
costs, everything, the provider salaries, the supplies, everything
that is specific to delivering covered RHC services. When you add
together these two types of direct costs - for covered and for non-covered
services - the result is the total direct cost for the practice.
Direct means you can identify them as being related to the service
in question rather than a general cost of being in business. For
some services - nurses; costs related to the legal requirements
of running your practice like general licensing of a clinic - I
call these special costs because they can be either direct or non-direct
depending on how well you can identify them as being connected to
a covered or non-covered service. The other category of expense
is indirect costs, things that you cannot specifically relate to
a particular service category. Sometimes benefits are direct because
the accounting system uses a method that records benefits with each
individual's wages and can therefore identify the costs related
to various support staff. More commonly, benefits and payroll taxes
are not carried in the books as individual entries, but are recorded
as total amounts for a practice. Then the benefits and taxes are
indirect and are distributed according to the percentage of allowable
direct compared to non-allowable direct costs in the total. Once
you get those total direct costs, you divide the direct non-covered
costs by the total direct costs, the result is the percentage
of your total direct costs that represent expenses for delivering
non-covered services. You then multiply this percentage by the total
indirect costs to identify your indirect costs for non-covered
services. If you follow the process with numbers like tens and twenties,
you'll see it very quickly and it really helps to understand.
Once you are done with this allocation of overhead,
the direct costs, plus the allocated non-direct costs for delivering
non-covered services are then excluded from your allowable RHC costs
on the cost report. Then, the total allowable RHC cost is divided
by the number of RHC visits to calculate your AIRR, your average
visit cost. I have an example at the bottom of slide 17 that shows
a situation where the RHC decides to provide patient transportation
because it's badly needed in the area. I've seen clinics do this.
They have patients who don't show up because they don't have transportation
or they have other issues, so volunteers provide transportation
or the practice buys a car or whatever. This is not a covered cost,
providing transportation to Medicare is not covered. It may be covered
and even billable for Medicaid; again you're back to your state.
But it's not covered by Medicare so you have got to get the cost
out of your accounting before the AIRR can be calculated. So you
take your direct costs for this non-covered service, expenses such
as gas, maintenance, the driver if paid, plus your indirect costs,
the percentage of the total indirect costs represented by the direct
costs for non-covered services. You add together the direct and
the indirect costs and remove them before you report your Rural
Health Clinic costs.
Bill Finerfrock:
We have about five minutes before we go to a
Q and A, Linda.
Linda Dartt:
OK, thanks. Finally billable, what's billable?
Out of all this confusion arises the day to day question, what can
I actually bill for, when can I generate a claim for Medicare, when
can I send a bill to Medicaid for something I've done? You have
to go back to your covered services, your covered providers, the
fact that you're a Rural Health Clinic and that encounter concept,
I added "for covered services only" on slide 18 because
you always have to remember that. Just because one of your providers
did it doesn't mean it's covered. They could get face-to-face with
a patient, they can do something, they can write it in a chart but
if wasn't necessary for them to do it, then you can't bill it and
if it's not defined as a visit-generating service, you can't bill
it. That includes all those nurse visits that practices record as
99211 procedure code because they don't require the presence of
a provider. Even though the service is covered, it is not billable
because a billable RHC provider did not provide it and if a billable
provider did deliver it, it still wouldn't be billable because it
did not require a provider.
I understand you can bill for 99211 in a fee for
service practice, but you cannot bill for it in a Rural Health Clinic.
You can keep track of it, I would. I would keep track of how many
times my nurses were doing things that I couldn't bill for, just
as another piece of information when I do an analysis, but you cannot
generate a bill for that in an RHC because a nurse-delivered service
is not billable unless it's delivered in one of those home health
shortage areas that you probably are not in and probably won't get
designated.
In addition, when your CPs and LCSWs deliver
services, you can bill your face-to-face encounters for a necessary
reason, but your payment will be limited by Medicare because of
the Part B limitations on mental health payments and a higher required
co-payment for the patient.
On slide 19 you have a definition of an RHC billable
visit that comes directly from Medicare. Lab, I mean, all the time
we get Nurse Practitioners who are doing a lab procedure themselves,
for whatever reason, they are taking a sample or giving an injection.
You have no face-to-face encounter here, you are not delivering
an RHC visit, you're not doing something that requires a visit with
a provider, so you can't bill it as an RHC service. Medicare has
a special situation for billing all lab work done in RHCs. In an
Independent RHC, the labs are all billed to the Part B carrier;
in a Provider-based RHC, the lab work is billed to the parent provider's
Medicare Fiscal Intermediary.
You will also have non-billable visits and I
just wanted to mention again, because somebody asked the question
about billing for prescription refills. This is a perfect example
of just because your Physician does it doesn't mean it's a billable
encounter. Your Physician can write a new prescription for that
patient or another provider can do it, but you can't bill for it
because it specifically says in the Rural Health Clinic manual that
whether the patient sees a provider or not, refilling a prescription
is not a covered service. However, including a medication refill
when the Provider provides a visit will increase the coding level
of the visit. That's important to remember even though you will
still only get paid the same amount no matter what level that visit
is for Medicare. You are documenting what you're doing, documenting
the level of the visits that you're providing. The fact that you
wrote a prescription adds to the documentation and the points that
you add up for deciding what level of visit it is. It also matters
in terms of providing high quality care and keeping good records.
You should know that you're refilling these prescriptions and how
often you're doing it and why you're doing it and whether the patient
has a medically necessary reason for coming in and should actually
see a provider. All of these factors go to tracking your patients
and taking care of them in a high quality way and making Medicare
happy.
I gave an example here of, theoretically, what
you would do if you wanted to exclude the cost of med refills, but
you don't have to because it's just part of your overhead, it's
part of what you do. Just like some practices call and remind patients
about their visits, some practices don't, well, it's part of the
overhead doing that. So, the cost will be included on your cost
report and become part of your AIRR.
Services delivered by telephone and advice given
electronically are currently not billable by RHCs, but there are
coverage enlargements that go on over time and I wouldn't be at
all surprised if in the next couple of years we can bill for a lot
of telephone delivered services because it's cheaper when a face
to face visit is not necessary and the payers will recognize that.
Your states may recognize telephone delivered services, and you
may have grant programs, you may have all kinds of things that might
pay you for these kinds of service delivery. There are a lot of
things that other payers - other than Medicare or Medicaid will
pay for.
All this comes together into building your average
cost rate. Your allowable cost total will be divided by your billable
visits, which is why it's so important to know what a billable visit
is. If you count too many visits, you're going to lower your per
visit cost. That's just math. If your total cost is hundred dollars
and you've got ten billable visits, you've got an average cost of
ten dollars. If you report that you've got twenty visits because
you misidentify billable encounters, you're telling Medicare that
you've got an average cost of $5, half as much, OK? So you want
to make sure that you count these visits appropriately because they
will be used to figure out your appropriate payment base rate.
Of course, there are other cost controlling factors
that can just get totally out of control and Medicare won't cover
for that matter. The critical access hospitals with provider-based
Rural Health Clinics currently have no cap. But most of you will
have a cap on the amount of your cost so you need to be careful.
Count every visit that you do legally but don't count ones that
are not legal because you won't do yourself any favors in the future.
You'll just have to undo it or the money will be taken back on an
audit. It's just not a good thing to do. You need to be careful.
You need know who you can bill for and then bill for them and count
them.
Bill Finerfrock:
We need to start wrapping up so we can move on
to the Q and A, Linda.
Linda Dartt:
OK. The last slide just really says Medicaid,
again, they use your all inclusive reimbursement rate as a guide
but they're not tied to, they used to be, but they are not anymore.
So again, you need to be active on a state level. States do need
to make interim payments and they do have some limits about reasonableness
and payments considering other practices and that sort of thing,
but you can find all the rules about Medicaid that are federal at
Medicare.gov, but the trend is away from federal control over our
Medicaid programs. It is definitely drifting in the other direction
so you need to make sure that you know what's going on in your state
and keep paying attention because it will change..
And finally the last slide, again, make friends
with the people who decide the policies and oversea coverage and
billing within you state government because you will have access
to finding out when things are about to change and what's changing.
Go to the hearings. In every state, when things are about to change,
hearings are held and they're announced and they're informational
meetings. You need to convince your bosses whoever they are that
this is worth going to or listening to if you can do it on a call
like this one. You've got to get as much information as you can
and sort through it and use it for your own purposes and don't ever
be afraid to ask a question because there are probably five or six
other people in the room who are thinking of the same thing and
not being willing to ask and none of you will get the answer to
the question if somebody doesn't ask it. You just have to ask.
All of us have learned about these programs by,
well maybe not all of us, but I learned a lot by being a pain in
the neck at Medicare with my regional office and with my local Medicare
Intermediary and asking questions, why is this not covered, why
can't I do this, what can I do in this situation?
Finally, remember the African proverb, if you
think you are too small to make a difference, try sleeping in a
closed room with a mosquito. It's quite a visual reminder of potential
power to keep in mind. Thank you.
Bill Finerfrock:
Thank you, Linda. We appreciate all the information
you've shared with us this afternoon. At this point, we'd like to
open it up to questions from the audience. The operator will give
you the instructions for opening up your line to ask a question.
During the question segment of the call, we request that everyone
provide their name and location, meaning, you know, city and state
before asking their question just so we can get a sense of the regional
or locational issues.
Operator, if you would give the instructions
for how people can ask questions.
Operator:
Thank you, sir. The question and answer session
will be conducted electronically. To ask a 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. Once again,
press star one for your question or comment.
We'll now take our first question.
Bill Finerfrock:
Go ahead, caller.
Julie Wesiling:
Hi, this is Julie Wesiling. I'm in Telluride,
Colorado. We're considered a frontier county. We've had a RHC status
for some time but have never utilized it. How would I determine
what type of RHC we are, whether institutional or individual?
Bill Finerfrock:
Well, Linda, if you want I can answer or you
can answer?
Linda Dartt:
Go ahead.
Bill Finerfrock:
All Rural Health Clinics when they are initially
designated are designated as an Independent RHC. Getting a provider-based
designation is a subsequent designation that you can obtain based
on meeting various criteria that CMS has laid out for any type of
entity that would seek to be provider-based. So I would presume
that you're Independent. A provider-based RHC has to be formally
tied to a hospital or nursing home or a home health agency and have
gone through the specific process for obtaining the designation
for that. So, are you part of hospital or nursing home or home health
agency?
Julie Wesiling:
No. We're Independent.
Bill Finerfrock:
Then you're clearly going to have to be an Independent
RHC.
Julie Wesiling:
OK, thank you.
Bill Finerfrock:
Next caller.
Jennifer Ryan:
Oh yes, my name is Jennifer Ryan from Estero,
Florida. I had a question regarding if we can charge a follow-up
office visit subsequent to a procedure code, like for example, an
incision and drainage?
Bill Finerfrock:
Linda, do you want to take a stab or do you want
me to?
Linda Dartt:
I'm not sure I entirely understand that, but
it sounds like he's done an incision and drainage and then the patient
comes back to have it checked?
Jennifer Ryan:
Yes, we repack and the Physician actually sees
the patient and treats them again possibly, not for another procedure,
but we repack it and possibly manipulate the incision, et cetera.
Linda Dartt:
Sounds like a visit to me.
Bill Finerfrock:
Sounds like one to me too.
Jennifer Ryan:
I was just under the impression it was possibly
inclusive is all.
Bill Finerfrock:
Inclusive in what?
Jennifer Ryan:
The previous procedure.
Linda Dartt:
This procedure you are doing has a global fee?
Jennifer Ryan:
Right.
Bill Finerfrock:
You billed it originally as a Rural Health Clinic
encounter?
Jennifer Ryan:
Yes.
Bill Finerfrock:
Yes, then your subsequent visit is another Rural
Health Clinic encounter.
Jennifer Ryan:
OK, thank you.
Linda Dartt:
That's important to remember. I think the only
time that global fees apply are when you've done something outside
of Rural Health Clinic services and you've billed it with a global
fee rather than as an RHC visit.
Bill Finerfrock:
(inaudible)
Linda Dartt:
If the patient comes to the RHC for follow up
and it's your patient, but you've already billed a global fee for
the original procedure, then you don't have a visit, but in your
case, you have two Rural Health Clinic visits going on here.
Jennifer Ryan:
OK, thank you.
Bill Finerfrock:
Yes, caller.
Susan Walsh:
Hi, my name is Susan Walsh from Laurinburg, North
Carolina. I have a couple of questions actually relating to billable
services in the Rural Health Clinic. We're a provider-based owned
by a hospital and I understand the Core of it is, is it a medical
necessity, but what about and actually the lady that just spoke
covered some of this, what about when you have a visit and the Physician
does a procedure and then you have a Core visit and he does an EKG?
Are those considered non-rural health and billed to part "B"
or do we roll those up into the Core visit or how do we bill for
those?
Linda Dartt:
Well, a stand-alone procedure would be different
than a general procedure. I mean, doing an irrigation or something
at the same time as a regular Core visit, you would bundle the charges
together - the charges would just be added together. Forget I used
the word "bundle". You would add those charges together
because it happened at one visit and the contact is a visit. However,
EKGs are a little different because they are diagnostic radiology
and, I believe, that if you can bill the non-encounter part of the
service (the technical component) to Part B in an Independent and
to the FI in a provider-based, but not as an RHC visit. The encounter
at which a provide decides to do an EKG is an RHC visit and can
be billed as such. Is that correct, Bill?
Bill Finerfrock:
The professional component is a visit. The technical
component gets billed as a Part B service.
Linda Dartt:
Right, and then the reading?
Bill Finerfrock:
The reading is part of the visit.
Susan Walsh:
So do you include the reading fee into your Core
visit fee? Do you add those two together?
Bill Finerfrock:
You're going back to what Linda said earlier.
You bill for an encounter and that encounter is all inclusive. Everything
that occurs during that particular visit that is a professional
service all gets added together for billing an RHC visit and you
get paid based on your all inclusive rate. Now you want to identify
the individual services that were provided because that will dictate
the beneficiary's co-pay during that particular encounter but all
the professional services get collapsed and billed out under your
all inclusive rate and that's what you're going to get paid on.
The EKG, as Linda said, is separately billable because it is a technical
service much like lab, a covered diagnostic service that is not
considered an RHC service and therefore is billable under Part B.
So that the only thing that gets taken out, you know, any lab services
that may have been billed during the visit, any technical component
of diagnostic services, those are billed out separately. All the
professional services are collapsed and billed under your single
encounter.
Susan Walsh:
And now just let me clarify this one thing, when
you say collapse, let's say my 99213 visit is $80 and my removal
of toenail is $20. Is my total charge to Medicare Part A a hundred?
Linda Dartt:
Yes.
Bill Finerfrock:
Yes, you're going to get paid based on your all
inclusive rate, whatever that is. Your charge is a hundred and the
beneficiary co-pay is going to be based on the hundred.
Linda Dartt:
Right. And that's part of the reason that's it's
important that the charge is right even though the payment may not
be different from Medicare.
Susan Walsh:
I understand that, OK, and that, does that -
what about injections? Same thing?
Linda Dartt:
Yes.
Bill Finerfrock:
Yes, injections, again, you're identifying the
charge for that but it's all collapsed into your all inclusive rate
because what you paid for the injection, the personnel who delivered
it are all captured on your cost report and reflected in your all
inclusive rate.
Susan Walsh:
OK, great. Thank you.
Linda Dartt:
I mean, I think that's one of the areas where
a lot of people get into trouble with the allergy shots and that
sort of thing that really do take more time and cost a lot. You
really have to think about whether it's a good thing to do in your
RHC because it will be included in a visit or it will just be built
into your rate if there is not face-to-face encounter.
Bill Finerfrock:
Here's a question that was emailed in ahead of
time. Can a Rural Health Clinic bill Medicare for registered dietician
service for medical nutrition therapy used in procedure code 97802.
According to the information that I have this service is listed
as a covered service but not a billable RHC visit. Why is that?
Linda Dartt:
It's just like having a nurse in your Rural Health
Clinic. I once worked in a hospital that owned some Rural Health
Clinics and they had a federally certified diabetic education and
management program with 2 certified providers (for their purposes).
It took a lot of effort for me to get everybody on the hospital
side to understand that if the Diabetic Nurse or the Dietician came
to one of our Rural Health Clinics and saw a patient, I could not
bill for it.
Bill Finerfrock:
Because the registered dietician is not a PA,
NP, CNM or Physician, the Dietitian's salary and other expenses
related to the service would be allowable costs, but the time that
the patient spends with them is not separately billable. So, back
to an earlier example, where we had the mathematical equation that
includes your costs in the numerator and your visits in the denominator
-- in this situation, you have costs in the numerator, but no visit
to count for the denominator.
Linda Dartt:
Right. That's a good way to put it because that
clearly shows that what you're doing is increasing the cost of a
visit and if you have a cap, you want to stay under it so you don't
want a lot of costs occurring with out visits to count.
Bill Finerfrock:
That's the problem we've been trying to get across
to Congress -- that operating in a capped environment and delivering
more services than was common 30 years ago, what that does is increase
your average cost per visit, which invariably puts you over the
cap if you're not there already.
Linda Dartt:
Right, but this is part of that circular thing
that's kind of, as the program evolves and people add services,
we want them to be a part of a Rural Health Clinic service, but
it takes some time for government and then the payers to catch up.
Bill Finerfrock:
Next question from a caller. This is going -
we'll take one or two more, Operator.
Operator:
Very well, Caller your line is open.
Bill Finerfrock:
Go ahead caller, someone got beeped.
Babs:
This is Babs from Baton Rouge. And I got two
quick questions. On page 10 you're talking about the Physician having
to provide the services one day every two weeks, does he actually
have to provide the primary care services or can he just be reviewing
he charts at that time?
Linda Dartt:
There's actually a requirement to provide services.
It's not well defined but it does say the Physician Medical Director
must "provide services". It says the Medical Director
must be present once in every two week period and that has been,
correct me if I'm wrong, Bill, but I think that most of the interpretation
of that has been at least a day every other week.
Bill Finerfrock:
Right, one day every two weeks is generally the
way that's it's viewed. There has
Linda Dartt:
The rest of it is, it says, deliver services
to patients. I think just consulting with your Nurse Practitioner
or whoever's on site and looking at charts and signing off is not
fulfilling the rest of that requirement. I think the expectation
and what I've seen in practice mostly, is that you will have some
patients during the week that the providers want a second opinion
about, or someone with more experience with the condition than they
have themselves, that sort of thing. So they want the Physician
to see the patient and once in every two week period is about as
infrequent as I would like to see that occur.
Babs:
Right, OK. Thank you.
Bill Finerfrock:
Next question is going to have to be our last
question. We will probably be doing sessions similar to this, I
think there always been a lot of confusion on issues of billable
and allowable so this isn't the end. And I would also encourage
you, many of you, I know, participate in the listserve. These are
good questions for the listserve. We'll take our last question from
the callers.
Linda Dartt:
I think it's very difficult to cram all the necessary
information into forty-five minutes.
Kelley Overbeam:
Hi, my name is Kelley Overbeam from Panora, Iowa
and my question is about billing for refills not covered. Does that
mean if a Medicare patient comes in for what our Physician would
call a med check, or whatever, goes over just to see how their high
cholesterol medicine's working or whatever and then writes a refill
at that time and charges a one-two-visit, a 99212, does that mean
we can't charge for that?
Linda Dartt:
He's charging 99211?
Kelley Overbeam:
No, the 99212, level two.
Bill Finerfrock:
A level two E&M visit?
Kelley Overbeam:
Yes.
Linda Dartt:
Yes, I would say that sounds billable because
you're doing a history and documenting it and you're not just refilling.
Kelley Overbeam:
OK.
Bill Finerfrock:
Yes, that's the subjective aspect of this is,
has the Physician provided a medically necessary service that requires
the skills and education of a Physician to that patient during that
face-to-face encounter. If it was simply to refill the prescription,
as Linda said, where there's no Physician judgment, no interpretation,
no evaluation occurring then it's not - that's not right for the
level of the visit but what you indicated is that the Physician
is checking different things, evaluating blood levels, doing whatever
they may need to do to insure that whatever prescription, the patient
is appropriately responding to, is not having an adverse reaction,
is not having some type - something occurring which requires their
medical judgment, now you've moved into a visit that Medicare describes
as a level two, so you now have a Rural Health Clinic visit.
Kelley Overbeam:
OK, thank you.
Linda Dartt:
Right.
Bill Finerfrock:
That's going to have to do it for today's call.
I want to thank all the participants; in particular, I want to thank
the Office of Rural Health Policy for sponsoring this series. A
transcript of today's call will be available in a few weeks and
it will be posted on the ORHP web site and we'll send out the link
once that is available. If you know others whom you think would
benefit from knowing about this series, we encourage you to share
the information and have folks sign up. We currently have about
11 hundred people who signed up to receive the information on this
series. We will have a call next month and will be announcing the
date and time of that call in the very near future. If you do have
suggestions for topics, please email those to info@NARHC.org.
Again, I want to thank all our participants for
being here today and look forward to having you participate in the
future. Thank you.
Linda Dartt:
Thank you, Bill.
Operator:
And that concludes today's program. We thank
you for your participation and have a wonderful day.
END
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