Operator:
Good day, ladies and gentlemen, and welcome to
today's Rural Health Clinic Technical Assistance Conference Call.
At this time, I'd like to turn the conference
over to your host, Mr. (Bill Finerfrock). Please go ahead, sir.
(Bill Finerfrock):
Thank you, Operator. And I'd like to welcome
everyone to today's call. This is, I believe, the seventh in a series
of the technical rural health technical assistance calls that we've
been doing on behalf of and in conjunction with the Federal Office
of Rural Health Policy.
Today's conference call will be on the Medicare
Advantage Plans, and our speaker will be Ron Nelson with Health
Services Associates. The program is scheduled for one hour. The
first 45 minutes will be Ron's presentation, and the remaining 15
minutes will be dedicated to questions and answers. As I said, this
call is sponsored by the Federal Office of Rural Health Policy and
is in conjunction with the National Association of Rural Health
Clinics.
In order to register for the series all of you
should, if you haven't, be registered, but you can go to www.ruralhealth.hrsa.gov/rhc,
and if you have questions for future calls you can send them to
info@narhc.org, and put teleconference question on the subject line.
With that being said, I'd like to welcome Ron,
and we look forward to your participation.
Ron Nelson:
Thank you, Bill. Today, we have a topic that
affects all of us in rural health clinics as it relates to the new
Medicare product out there, formerly referred to as Medicare Choice
or Medicare Plus Choice, now referred to as of the Medicare Modernization
Act as Medicare Advantage.
I want to preface this presentation by also pointing
out that there are lots of inconsistencies out there in the application
of the Medicare Advantage Program. We've had inconsistencies in
terms of interpretation at times from regulators, as well as inconsistencies
in terms of communication from the companies that are developing
the plans under the Medicare Advantage Program.
What I'm going to do today is try and provide
you with information that will provide some clarity and also, hopefully,
to identify some specific principles or questions that you should
be asking as it relates to entering into any type of managed care
agreement, but also specifically looking at questions you should
be asking in terms of providing care to Medicare Advantage beneficiaries.
I will also preface this by telling you some
of the things that I'm going to tell you are based upon market experience
and what plans are telling clinics and providing in their marketing
materials, and at times seems to be in conflict with regulation,
and other times seems to be different than regulations. So, I want
to preface it by saying there still is, I think, a lot of information
and interpretation to occur within this program.
The first thing I think is important is to understand
that the Medicare Advantage Program has evolved out of what was
previously referred to as Medicare C or the Medicare Plus Choice,
and that occurred with the Medicare Modernization Act of 2003. It
created a program to offer two basic types of products, which we
will talk about in a minute. But I'd like to just address where
Medicare C and Medicare D, the prescription drug benefit, fall under
this Medicare Advantage Program.
The Medicare C, as it was referred to previously,
is now what is referred to as the Medicare Advantage products. The
Medicare D, which is the prescription drug benefit may or may not
be part of the particular plan you're dealing with under Medicare
Advantage. In some cases it may be a separate benefit. In other
cases, it may be included as part of a Medicare package which includes
the traditional Medicare coverage, the coinsurance portion, and
the prescription drug benefit.
I think it's important to understand that Medicare
Advantage really provides two types of plans. The first type is
a private fee for service plan which can be marketed and provided
in any area by a plan that has met the requirements in providing
a certain set of benefits that are required to Medicare beneficiaries.
The private fee for service is probably the most significant portion
at this time that is affecting rural health clinics because the
other type of a plan which is a regional plan have not proliferated
nearly as much because of requirements and marketing differences,
which we will talk about in a few minutes.
The regional are plans that have been created
based upon regions that have been developed by CMS and you have
in your handout a map which shows the actual regions of the country.
The regions are made-up of either a single state or multiple states
to form a particular area that a regional plan might provide or
would be required to provide services if they're going to service
a region.
The regional plans do require service to the
entire area. There are some interesting differences in the regional
PPO plans in that they have some relaxed network standards as compared
to the normal standard of providing certain types of networks, such
as travel time and number of providers in a particular region or
community. It appears that CMS has allowed a relaxation of some
of these standards as compared to the Medicaid model which many
of us are familiar with has been implemented over the last several
years.
The regional plans also require a contract for
which you must enter into a contract with a regional PPO. There
is another model as a subset of the regional PPO referred to as
the local network PPO, and they also will require a contract with
the RHC. It requires a negotiation of rates and there's no requirement
for the plan to pay the RHC rate. They may pay the RHC rate if it
is negotiated but certainly is not required and there is no wraparound
protection in legislation or regulation that requires that you be
paid an additional amount up to your full cost based rate.
The private fee for service plans, on the other
hand, have different characteristics in that there is no contract
required. However, you may sign a contract with a private fee for
service plan. They do create what's referred to as a 'deemed status,'
whereby a patient may come into your rural health clinic, and if
you accept their card and see the patient they are then deemed that
you are a deemed participating provider because you've accepted
that patient and treated them. But it does not necessarily require
that there's a contractual relationship between you and the beneficiary.
One of the things that seems to be in conflict
is that beneficiaries may change their plans monthly. I've attended
several presentations where plans have informed individuals, providers
and beneficiaries that they may change. On the other hand, I've
heard communications from individuals at the federal level indicating
that this is not allowed in the private fee for service market;
however, I think at this point in the marketplace it indicates that
members have been able to change plans if they choose on a monthly
basis.
I think it's important that before we go into
some more of the specifics on Medicare Advantage to just review
some of the requirements of the RHC Program under traditional Medicare.
First of all, the RHCs must be paid a rate as determined by their
cost report and subject to the appropriate limits or caps. The traditional
RHC services are billed to the intermediary and paid based upon
an all inclusive interim rate which is determined by the cost report.
The RHCs are paid their full cost as an add-on
in the cost report for vaccines based upon supply costs, vaccine
costs, and labor. RHCs are also entitled to recovery of bad debt
under Medicare for Medicare beneficiaries as an allowable item on
the cost report based upon a reasonable effort of the minimum of
120 days and appropriate documentation of reasonable effort to collect
that money.
RHCs that are provider based that have more than
50 beds are paid a rate which is an all inclusive interim rate determined
by a projected cost report and paid subject to the caps, as we've
already stated. Those provider based with less than 50 beds are
entitled to the full cost per visit with no limit or no cap on the
rate.
The Medicare Advantage, as I've said already,
has created two basic types of plans, the private fee for service
and the regional network of PPO type of plan. It seems from the
data that I've looked at most recently that the greatest proliferation
has been in the private fee for service market.
On the private fee for service market there is
a requirement for the private fee for service plan to pay a rate
to the RHC that is equal to their cost based reimbursement. There
is no contract. It is patient driven, and this is where it sometimes
creates conflict for those of you in the rural health clinics you
will find that salespeople representing these plans are selling
cards to patients covering them under this plan and, in fact, not
giving them necessarily all of the information.
Unfortunately, the patient presents to your office,
there's no requirement for a contract, and the patient assumes based
on the conversation with the marketing representative for that plan
that they can come into your office and get the services as was
outlined to them, generally for a minimal co-pay of $10 or $15.
What happens is no one has discussed with the
patient that there are specific requirements for payment for rural
health clinics, and so we get into a conflict between the patient
or beneficiary and the rural health clinic that's been created by
the sale of that particular card to the beneficiary.
The fee for service Medicare Advantage Plan may
include both the Part A and Part B portions of Medicare.
It may also include the prescription coverage.
It is not uncommon in many of the plans to see that they offer options.
Option 1, option 2, option 3, which may include both Parts A and
B and the coinsurance portion and not include the prescription portion,
or may include all of those above, including the prescription portion
with different deductibles and co-pays relative to prescriptions.
One of the things that's important for us to
understand is while I said earlier that the fee for service plans
are required to pay up to your rate there is no requirement at this
point or at least CMS is not requiring the RHCs to cost settle.
I think some of us would argue that the regulations legally do require
the ability for you to get your full costs which could necessitate
cost settlement. However, CMS at this point has not directed the
plans in the private fee for service market that they have to cost
settle with the RHCs.
What that creates is the opportunity for you
to now negotiate with the plan and determine how you might increase
the rate that they're paying you in exchange for not cost settling.
And I think that's a point we will talk about a little later when
we get into discussion regarding negotiation.
The regional network plans as I've talked about
already, are plans that are required also to negotiate rates with
RHCs. They are generally required to cost settle with those that
are less than 50 beds, but there's no requirement for a full payment
rate to independent or provider based greater than 50 beds, and
they must have a contract with the rural health clinic. There is
no wraparound that is required for the private PPO plans in terms
of payment to the RHCs, nor is there a wraparound required for CMS
to facilitate to make the RHC whole as it relates to their full
RHC rate.
Now that we've covered some of the basics relative
to the differences in the Medicare Advantage Plans, I want to move
to really trying to give you some information and what I hope are
some tools to deal specifically with the Medicare Advantage Plans.
And the first thing that I cannot stress enough
is as rural health clinics we need to understand we do not have
to accept someone walking in and saying, 'here's what you're going
to get paid, sign this,' or 'here's what you're going to get paid,
accept this." You have the opportunity for negotiation. And
it's important that you develop a rationale and a methodology as
to how you will negotiate. Who within your practice is going to
conduct that negotiation? And what information do they need to be
able to negotiate with a plan?
Some of the questions that you must ask when
you start to talk about negotiation is who is going to be signing
the contract with this organization if a contract is required? Does
the plan limit particular types of medical services? In other words,
is it more inclusive in terms of the types of benefits that are
covered or is it limited only to the traditional Medicare benefits
in terms of what's covered?
How many individuals are currently in the plan?
Who are the major employer groups that may be involved with the
plan? People typically don't think of the Medicare Advantage as
being a product that is part of the employer groups, but what clearly
seems to be evolving is a strategy for Medicare Advantage Plans
is to look at providing the opportunity for the retiree type of
benefits for some of the major employers. So, it's important to
understand if they have relationships with major employers currently.
What is the financial condition of the plan?
Who owns the plan? What is the history of the plan's payment to
providers? In a recent presentation someone asked, 'are they held
to the minimum payment floor for Medicare?" And the plan's
response was, 'our payment is far better than Medicare's, so we
don't worry about a minimum floor in terms of payment for our RHC
services."
What is the experience of other providers? If
you have the opportunity to communicate with other providers who
have had experience with that plan it's important to talk to them
and share some of your experiences as it relates to negotiation
and how they might recognize and pay for the services in your rural
health clinic.
One of the things that comes out frequently in
managed care type of plans is the requirement to use a specific
laboratory service. So, what are the laboratory services if there's
a specific required lab? Or can you send patients to any lab to
receive laboratory diagnostic services? How do they deal with complaints
and problems relate to pick-up of specimens and services? Those
are all important issues to those of us in rural health clinics
who rely many times on reference labs to perform services for our
patients.
What does that plan require in terms of authorizing
a hospital admission? Is there a prior authorization process? Is
it necessary to certify any type of length of stay for the patient?
And are there non-covered services in that plan which are defined?
Some of the other questions that you might ask
that are specific to your practice but may also affect all of your
managed care is how do you handle disruptive patients? What if you
have a patient who comes in and is threatening or is disruptive
and you want to discharge them, do you have specific requirements
as to how you discharge them from the practice?
Are you notified when someone is no longer in
the plan? Do they have them in the plan and then all of a sudden
they've dropped them from the plan but they don't bother to notify
you? How do you get notified, and who pays if, in fact, you are
not notified and aware that they're not in the plan?
What services do they track in terms of profiling?
One of the things that we know is part of the impetus for moving
more and more to managed care is to collect data and information
that allows us to analyze how services are provided and hopefully
begin to look at outcomes and best practices. So, what kind of data
is going to be collected regarding your practice? And how will you
access that data as you become a participating member of that particular
plan?
Some of the specific questions when we get down
to the RHC issues and being paid, I think we have to begin to look
at how the payment compares to your own fee schedule or your own
current payment from Medicare?
What I suggest to people is that you take your
current per encounter rate and look at what you're getting as 80%
of that rate from your FI, and do a modeling of the proposal that
you are getting from the plan. What I have found from some is that
based on the way they're doing their calculations you may be getting
less from the plan than you're getting from your current FI.
And be careful because plans will show you models,
and I've seen this recently in a couple of occasions, where the
models they've used has assumed a $100 charge to calculate how they're
going to pay you. And $100 charge may not be the average charge
in your practice, and, in fact, I would submit for many of you it's
probably closer to $70 as an average. So, therefore, their calculations
are off at the outset because they're using an inflated, unrealistic
charge to use as a model.
How does it compare to your encounter rate? What
are the turnaround times in terms of claims payment? Those are all
critical questions that you need to ask when talking with the plan.
How are they asking you to submit claims, and what is the turnaround
time that you will get on a clean claim?
If you perform certain lab or X-ray studies,
diagnostic studies in your office, how are you paid? For example,
many of the plans are proposing to pay your rate plus they're going
to pay you fully on the fee schedule for the diagnostic studies,
such as EKGs, and other studies that you do within the office. And
in those particular cases the reimbursement on their fee schedule
is significantly higher than what you're currently getting under
Medicare Part B. Therefore, you may do better in terms of looking
at the ancillaries that you're performing and billing within your
offices.
So, some of the other questions that we need
to begin to focus on as rural health clinics are when you negotiate
a rate and you say to the plan, 'look, I'll accept your patient,
private fee for service, or regional PPO,' that when you negotiate
that rate that you ask them when they're going to adjust your rate?
And an example, rural health clinics have fiscal yearend that can
exist more commonly 12/31 but maybe 6/30, maybe 9/1, maybe anytime
during the year based upon your fiscal year. It is important that
you ask the plans when they are going to adjust your rates based
upon when your rate will be adjusted also from your cost report.
As you all know, you submit your cost report
within five months of the end of your fiscal year, then you normally
within about a 90-day timeframe receive notice of your new rate.
so, when is the plan going to implement that rate? And are they
going to coincide the implementation rate with the same effective
date that you're hearing or you're getting currently from your FI.
I believe that based on the regulations they have to adjust it based
upon those dates, but I think those are questions that you have
to ask to try and gain some clarity and some understanding of how
they intend to pay you.
How do they define their cost and payment? Those
are some questions that you need to ask in terms of how they're
defining what services fall into the particular service that you're
providing. For example, are injections billed separately on the
fee schedule and paid separately? Therefore, they're not included
as part of the visit as they are in the rural health clinic billing
model. That's obviously a difference and may be an opportunity for
you to capture additional revenue.
The year end settlement is a question that we
have been told by CMS they will not require settlement from the
plans as it relates to working with RHCs. However, I have heard
at least two plans say that they are willing and open to if the
RHC demonstrates to them additional revenue that should be due to
them and that they were not able to capture their full rate that
the plan is willing to pay them based upon appropriate documentation.
The question obviously is always in the details, what's appropriate
documentation? And I haven't seen any examples that I could share
with you at this point.
Another question that has come-up is how are
you paid for vaccines? How do you get your influenza and pneumococcal
vaccines? Currently, you calculate the cost based upon supply costs,
labor costs, and vaccine cost to come-up with a cost per vaccine,
and you keep a log of those Medicare patients and it is an add-on
in your cost report to be reimbursed at full cost for those vaccines.
My experience is that the plans have offered
a model that allows you to get paid at a reasonably calculated fee
screen but is not at the cost based level. You have to do some comparison
of the impact that that will have on you in terms of receiving less
on a fee schedule than you would have received on the cost basis
but there are some other tradeoffs when you look at other injectibles
that you will now also be paid on a fee screen that were previously
bundled with a visit. So, it's important that you take a look at
the vaccine issue.
Medicare bad debt allowance, you are entitled
to bad debt recovery from Medicare. Some of the plans will argue
with you, you won't have bad debt. For example, I have seen plans,
private fee for service plans offer a reimbursement of the full
rate that you currently are being paid plus you get to keep the
$10 patient co-pay. Therefore, you are receiving now more than you
would have received under your Medicare RHC program reimbursement.
What they say is you have no bad debt, therefore,
we're not going to offer to pay you any bad debt recovery. There
are other plans that are not quite as generous in their offers and
have talked about offering the opportunity to submit at yearend
appropriate documentation of what you believe is valid Medicare
bad debt and they would entertain paying that bad debt obligation.
Questions that you need to ask related to the
contract include the length, if you enter into a contract, how long
is the contract? You need to ask questions for claims processing.
It seems we have enough complexity as we started this program in
1977 it was to be simplistic and one rate was paid for all services.
As those of us who have been involved for many years have seen,
we have created more and more complexity and carve-outs and diagnostics
not being part of the rate. Hospital services no longer being part
of the rate.
And it seems to me that we do not want to add
additional complexity in the billing to this process, therefore,
I have seen many of the plans have said that they would process
the claims exactly the same as if you were submitting them to their
FI. You would just submit that UB92 format now to the Medicare Advantage
Plan and they will pay it from the UB92 format. The question you
have to ask is will you bill them the other services on a 1500 or
do you add each service as an additional line on the UB92, different
than what you do now, as you bill for those services? Those are
questions that you need to ask of the plan when you're negotiating.
Timeframe for payment of clean claims, what is
the typical time? Should you expect payment within 10 to 12 days
on a clean claim? And, again, I want to reemphasize the importance
of asking the question how are the rates adjusted? On what basis
are they adjusting your rates, and when do they go into effect.
If you send them a copy of your notice of your new rate today does
that mean they're going to implement the rate as of today even though
it was effective five months ago? Or are they going to implement
the rate effective five months ago and pay you some type of adjustment?
So, you need to ask, I think, specifically how those rates are going
to be adjusted.
How are you paid for non-RHC services is another
very critical question. What about other services that you provide
within the rural health clinic. Within the rural health clinic might
be the other diagnostic services that you provide, procedures that
you provide in the clinic, and even questions such as hospital services,
how are you reimbursed for those services?
How does the plan address the services provided
by PAs, nurse practitioners, or certified nurse midwives? Since
these providers are statutorily required to be in the clinic how
are they, in fact, going to pay for those services. Unfortunately,
many of the insurance companies who have gotten into the Medicare
Advantage business have previously had history of taking an approach
with non-physician providers, such as PAs, NPs, and CNNs, that they
are not going to recognize or cover those services. So, here you
now have companies that are now in the Medicare Advantage business
providing services where clearly PAs, NPs, and CNNs are authorized,
how are they going to recognize and how are they going to process
claims for services provided by these individuals?
Does the plan cover behavioral health? The behavioral
health is part of that benefit, then how is it covered and are they
going to cover a clinical psychologist, a clinical social worker?
Does the clinical psychologist have to be a Ph.D., such as current
Medicare regulations allow? Or can it be a limited licensed psychologist,
such as most of the Medicaid programs now accept in terms of providing
services to RHC beneficiaries.
Is there a credentialing requirement? Are they
going to require that the providers in your rural health clinic
must be credentialed in order to provide those services? And, again,
you must ask the question, "how do they credential PAs, NPs,
and CNNs since they are a critical part of the requirement for the
delivery of services?"
How are the incidental services, such as injections
are paid for? I've stated this once. I want to restate it. It's
important to understand. You have an opportunity potentially if
these are paid in addition on the fee schedule to capture some additional
revenues.
Do the co-pays for RHC versus non-RHC services
differ? Is there, for example, a different co-pay for service provided
in the rural health clinic versus a service you might provide at
a skilled nursing facility, at the patient's home, or in the emergency
room or the hospital?
Do they recognize certain RHC services as separate
for Part B similar to what we have currently in the RHC program?
As an example, hospital admissions on the same day and a clinic
visit? Currently, under the regulations that exist, and RHC is a
distinct separate benefit. If I see a patient in the rural health
clinic and then the patient is admitted to the hospital and the
work is done in both places I can bill both the RHC visit and the
Part B portion for the hospital visit. If the Medicare Advantage
Plan is now covering both are they going to pay for both? Or are
they going to try to implement a rule saying, 'we'll only pay for
one service in a single day.'
A definition of what the core services are in
the rural health clinic by the Medicare Advantage Program. What
do they recognize as RHC services. Is the skilled nursing facility
considered to be an RHC service and, therefore, you rate is paid?
Or are they going to pay you on a fee schedule for that? Is the
patient's home considered to be a RHC service or is it going to
be paid based on the fee schedule? The patient's home, for example,
you may receive greater reimbursement on the fee schedule from the
Medicare Advantage Plan than you would from the RHC program under
your rate if you are currently subject to a cap. And, of course,
how do they deal with the services that are incident to a professional
visit from an RHC provider?
Some of the other questions that I think we have
to ask as we look at this program is the tracking of data. And I've
had several questions funneled to me and to others that have been
presented regarding well, how does this fit within the cost report?
And, unfortunately, the only general answer that I can give you
is that the cost report currently is for those services that are
Medicare covered under an RHC and do not include those services
for private insurance, and, therefore, the Medicare Advantage would
be treated very much like a private insurance. While it's a Medicare
service and it's a Medicare visit you would not be including those
as part of a count that you would be submitting to your FI because
they would only be cost settling on those visits that are recognized
regular Medicare services or patients that you provided services
to.
So, you're going to have to create a separate
tracking mechanism for your Medicare Advantage patients to keep
track of the services that are provided. If nothing else, for administrative
and management purposes to be able to effectively understand what
it's costing you to deliver service and if this is having a positive
or negative impact on your practice?
So, some of the questions that I would ask a
plan is will they provide a PS&R type of report? Can I get a
report from the plan on an annual basis, at least, and maybe even
more often detailing the visits that were provided, the co-pays,
the deductibles, and any payments that were made? This would greatly
enhance from a management administrative standpoint your ability
to track this data. It's, again, a negotiating point. You're potentially
going to give-up cost settlement. You're potentially giving up several
other areas where they would be required to administratively calculate
your payment.
And the question you have to ask them is what
is it worth for me to give-up these things for you to pay me to
assure that when I give them up that I'm not losing in the end?
So, the tracking is a reasonable request to ask of those plans.
What kind of data, report and breakdown will
they provide by provider? For example, if you could get them to
provide you the same reports by provider that can be very effective
and I believe powerful information going forward as you look at
contracting with a particular plan.
The last portion of the presentation that I have
today highlights some information that I thought was important based
upon a multi-center approach to surveying critical access hospitals
and taking a look at what critical access hospital administrators
had had in experience in dealing with Medicare Advantage.
And this comes from a rural health policy brief
which was December of this, '05, just this past month. And I have
some quotes in the handout that highlight some of the issues that
critical access administrators saw in dealing with Medicare Advantage.
And I think, most importantly, was the ability to negotiate. And
the fact that many of the administrators felt that they previously
didn't have as much opportunity as they may now to really negotiate
with the plans.
The other problem that we heard, and I think
at least from the information that I read in the policy brief and
some discussion with the researchers that collected that survey
data is that many of the administrators felt that they weren't contacted
by the Medicare Advantage Plans. So, for you to sit back and just
assume that someone will contact you is probably the wrong thing
to do, and, in fact, you need to reach out. If you know there are
plans in your area that are actively marketing either as a regional
PPO where they're going to have to come to you with a contract or
as a private fee for service where they don't have to come to you,
you need to reach out and ask to sit down with them to have some
discussion.
Another area that was highlighted, I think, by
the administrators was relative to contract language. Be sure that
you look at the contract language if you're offered a contract,
closely, to have a good understanding of what they are really offering.
Be sure you're clear about timeframes and how you're going to be
paid, and try as best you can to maximize your position to get as
close as possible, if not at or above your current rate.
So, in summary, I think it's important to recognize
that the Medicare Advantage has now created a different model and
a greater influence of market forces on rural health clinics as
one of the safety net providers in rural America today.
What it has done, however, is it has put rural
health clinics in a position whereby you can negotiate. You have
the ability to look at a plan and say, 'if you want me to take your
card, private fee for service, or accept your contract as a reasonable
PPO I need to know what it's worth for me to, for example, not require
a cost settlement on my patients. What is it worth for you not to
have to pay me costs on vaccines? What are the opportunities for
you?"
I think the most important and key part of this
is to recognize the opportunity that exists for negotiation. It
has value. Don't assume that you have to accept what's being offered
to you. And I have listened to I think almost every line about,
'oh, we can't negotiate, we're not allowed to negotiate." And
yet I've seen those same plans when actually sitting down with their
feet to the fire, so to speak, have negotiated with the rural health
clinics. So, I really want to stress to you the importance of sitting
down with them and negotiating what is best for your rural health
clinic.
I have attached, also, as part of the presentation
several common terms that I think are being used in this scenario.
I would like to encourage any of you who have interest in understanding
more about the regional PPOs and the regional contracted plans in
your regions to go to the CMS web site and pull off the map, the
map that I have for you in the presentation is one of many that
exist that look at the regions and how they're broken out which
might give you some additional information.
CMS also has a list on their web site of the
various plans that are currently in the regions and will be apparently
locked in for the next two years in terms of no new plans being
created in those areas.
Again, I want to stress to you the importance
of trying to understand your marketplace. Who, from a Medicare Advantage,
is in your community? Most likely it's a private fee for service
plan. Some of you may be affected also by regional PPOs. On the
private fee for service because a patient presents to your practice
and says, 'I'm here, I now have a card from X, Y, and Z,' I think
it's important for you to understand that doesn't mean you have
to accept X, Y, and Z.
I also am not aware of any regulation that precludes
you from saying to your patients, 'these are the plans that we're
going to take, or that 'the' plan we're going to take, and this
is the one that we would like to see you enroll in if you're going
to go into a Medicare Advantage product."
That, again, is a very powerful negotiating tool
for your ability to influence patients and use that as a negotiating
tool when you're talking with plans in terms of ensuring your rate.
I want to take this opportunity now to also suggest
to you that the National Association of Rural Health Clinics is
doing a Spring institute March 9th and 10th in San Antonio, Texas.
A large portion of that conference is going to be dedicated to Medicare
Advantage. It is our belief that in another six weeks we will have
a lot of additional information and maybe even some additional clarity
on some of the issues that seem to be gray as it relates to Medicare
Advantage.
I would encourage all of you to participate if
you can and try and attend or send a representative to attend this
important meeting as Medicare Advantage has the potential to have
significant impact on us in the rural health clinics.
I think we've completed the first 45 minutes
of the hour, and at this time I'd like to turn it back for the q-and-a
portion.
(Bill Finerfrock):
OK, Operator, would you please explain to the
participants the call-in, how to be able to open their line to pose
their question?
Operator:
Yes. If you'd like to ask a question at this
time, you may do so by pressing star one on your telephone. A voice
prompt on your phone line will indicate that your line has been
opened. We ask that you please state your name before posing your
question. Once again, that's star one please.
(Bill Finerfrock):
And if you could also let us know where you're
calling from, what state, area of the country you're calling form?
Operator:
And we'll take our first question.
(Jerry Payne):
My name is (Jerry Payne). I
(Bill Finerfrock):
Speak up caller?
(Jerry Payne):
My name is (Jerry Payne). I'm with Pacific Care.
And we are offering private fee for service plans in the service
areas in Texas involving RHCs. I, first of all, wanted to make a
comment that much of what I have heard today certainly applies to
the regional PPO plans.
There's one distinction I would like to make
with respect to the private fee for service. The direction we have
received from CMS is that because these private fee for service
plans are supposed to be portable and taken to any provider who
is willing to agree to the terms and conditions of the plan that
we cannot contract and we cannot negotiate because what we do with
one we do with all.
Secondly, we have developed a reimbursement method
that has been approved by CMS as well as the National Association
of Rural Health Clinics that in essence pays above your interim
rate and pays above the RBRBS for services that fall outside of
that.
I have an example that I can provide to anyone
who is interested.
(Bill Finerfrock):
Jerry, I appreciate that. I don't know that this
is a reasonable way to do that. But I think you guys are going to
be participating in the San Antonio Conference?
(Jerry Payne):
That is correct.
(Bill Finerfrock):
And you'll have information there. And we'd certainly
be happy to try and put information out to help folks better understand
whatever you want to share. We can post that on our web site or
get it out.
The only thing I would say is that while we -
you said that we approved what you did. We have no approval process.
(Jerry Payne):
I said you had reviewed it.
(Bill Finerfrock):
OK, I'm sorry. I thought
(Jerry Payne):
No, you have reviewed it and found it acceptable.
(Bill Finerfrock):
OK, thank you. I mean was there any specific
question that you had?
(Jerry Payne):
I think I just basically wanted to draw the distinction
from the regional PPO plans about their being no negotiation and
we're not allowed to do any written contracts. That was my - that
was the thrust of my comments.
Ron Nelson:
Jerry, let me just say, I appreciate your comments.
And I have just spent the last, the better part of the last three
days at a conference in Washington with many people, a large portion
of which was focused on Medicare Advantage. And I can tell you that
there were three different people there who all felt that there
was an opportunity for contracting.
And I can tell you under the private fee for
service and I can tell you of plans who are proposing that, which
gets to part of my point earlier for people to understand is while
we believe that there is uniformity in how this is being applied
it's becoming more and more clear, if I can use that word in this
discussion, that there is not necessarily uniformity in how it's
being applied. So, I think that's the important point for the clinics
to get understanding and appreciate what you've been told and what
you've been instructed from CMS. Other plans are doing other things.
Thank you.
You had another caller?
Operator:
We'll take our next question.
Jim Dixon:
Yes, this is Jim Dixon from Copper Queen Hospital.
We operate two rural health clinics inn (Disbe), Arizona, and we
are an access waver state and the problem we're running into is
with the duals. Access is our Medicaid and what has happened is
with the duals the access provider, which is the Arizona AP IPA,
Arizona Physicians and that, are not negotiating. What they did
was gave us a rate of the fee schedule for Medicare, not our cost
as indicated in our cost report to Medicare, and told us that they
wanted to give us a 5% discount off that rate. There was no negotiating.
They told us they would switch the patients if we didn't sign to
other providers. And also we were formerly doing Medicare labs in
the hospital and they told us that we can no longer do those, they've
got to send them to an outpatient lab. This is really, has a detrimental
affect to the hospital.
But the states that are highly Medicare Advantage
care penetrated are seeing this heavy handedness being performed,
and they're not negotiating. I wish I could use all the negotiating
points that you had put forward. But basically they are not understanding.
First of all, they didn't understand what an RHC was. So, we had
to explain that to them. They didn't understand how we're reimbursed.
And then what a critical access hospital was. And so these plans
are ill prepared for negotiating at this point.
We signed a bunch of contracts that said they'd
pay us the Medicare rates. They don't understand who they're signing
with or what they're signing with. And so it is really a mess right
now, and it is not getting any better.
Ron Nelson:
I would certainly agree with you. And what I've
heard from you is not unlike things I have heard from other individuals,
hospital administrators, clinic administrators, in terms of the
kinds of problems that are existing out there.
And the biggest one is the lack of knowledge
on the part of the plans in understanding what a rural health clinic
is. But I think more importantly is then the requirement for CMS
to, in fact, make sure that they are properly following the regulations.
And I think you're also affected here in the
managed care side by if there are other providers in the community
is that the managed care model says that they're going to threaten
you with, 'well, if you don't sign it and take what we offer we're
going to send the patients elsewhere.'
Jim Dixon:
That was eminently clear.
Ron Nelson:
And I think
(Bill Finerfrock):
One of the problems you've got, though, is somewhat
what you're experiencing in Arizona is unique in that Arizona does
operate under a statewide waver under the access
Jim Dixon:
Absolutely.
(Bill Finerfrock):
Which eliminates on the Medicaid side beneficiary
freedom of choice. And so some of the ways that they're able to
do some things, I think in Arizona, are not completely unique but
somewhat unique because of the way that the state has established
its Medicaid program.
Jim Dixon:
The other thing is I know that there's a federal
law, HR880, which was going to give us in affect a waver, making
them pay us under the current existing system which stalled in committee.
They did give FQHCs a waver from this Medicare Advantage. And I
think that it's important that everyone listening, that we should
push the Congress of the United States to pass some form of 880
to put us back on the same footing we were prior to this Medicare
Advantage program. Otherwise, if it doesn't happen this year it's
going to happen next year or the following year, because once they're
held, that 8 billion or 10 billion of hold harmless is gone then
they're going to start applying heavy handed managed care tactics
to make a profit. And they're going to really decimate the rural
system.
(Bill Finerfrock):
In terms of that the bill that you're referring
to, 880, would also provide some coverage for RHCs. It deals with
critical access hospitals and rural health clinics. The wraparound
payment, there is, a few HCs are non-exempt from Medicare Advantage.
What they have is a wraparound payment that Medicare would make
them whole relative to whatever they've negotiated or get paid from
by the managed care entity. It may be less than what they were entitled
to as an FQHC.
Jim Dixon:
The question that comes to my mind
(Bill Finerfrock):
We are also working to get that done, as well.
We, as a national association of rural health clinics, we appreciate
that, and that is something that we are working on. So, you know,
we would welcome your support and we're very interested in getting
that kind of legislation enacted.
Jim Dixon:
What, in your experience, would lead you to believe
that why would they do it for FQHCs and not do it for RHCs and hospitals.
It would seem to me that they're trying to back-off the commitment
that they've made to these two other entities and out of a belief
that there are too many or they're too costly, and think the FQHCs
are more important. Why weren't they - we weren't included with
the wraparound originally?
Ron Nelson:
I think it was a political decision that was
made and there were things that were going on during the Medicare
Advantage debate and the way this all came about that is really
more reflective of why that happened. But I can tell you that the
cause and the RHCs are looking to try and get a similar kind of
a wraparound payment.
One can draw whatever conclusion they choose
from why one was done and the other not, but we are working to try
and get that rectified. And I know that NRHA on behalf of the cause
is trying to do that, as well.
Jim Dixon:
Thank you.
Operator:
We'll take our next question. Linda, your line
is open. Please go ahead.
Male:
Hello.
(Bill Finerfrock):
Hello.
Linda Willis:
Hello?
(Bill Finerfrock):
Yes.
Linda Willis:
OK, I guess that's me then. This may be a very
stupid question. Is - we have a provider based rural health clinic
here. I'm in Louisiana. I'm Linda Willis with the rural hospital
coalition. That wants to open up a provider based mobile rural health
clinic, and we are being told, this hospital is being told they
cannot do that.
(Bill Finerfrock):
Who is telling them that?
Linda Willis:
The state agency.
(Bill Finerfrock):
Well, the federal law and the regulations provide
for mobile rural health clinics, so I'm not sure on what basis they
are determining - if they're telling you flat out that it can't
be done that's not true, unless there would be some kind of a state
law that prohibits a mobile clinic from existing in the State of
Louisiana, but there's nothing in the RHC statute that would prevent
you from having a mobile rural health clinic.
Linda Willis:
Even though it's provider based?
(Bill Finerfrock):
Yes, there's nothing that would restrict you
in terms of, again, your ability to have it. You know, we'd have
to look at the details, what it is that you're proposing, the market,
the locations that you're proposing to have that based in, et cetera.
But there is not an absolute prohibition against having a mobile
rural health clinic and, in fact, the regulations specifically say
that a clinic can be mobile.
This is probably a conversation that would be
best to have in more detail individually rather than on this call,
and if you want to give me a call it's 202-543-0348, and I'd be
willing, I'd be happy to talk to you more offline.
Linda Willis:
Do you mind giving me that number again?
(Bill Finerfrock):
202-543-0348
Operator, I wanted to take a question that we
got e-mailed in prior to the call. This is from (Diane Cartimone)
from Hickory, North Carolina. She said that she's been informed
by River Bend that encounters with patients on a Medicare Advantage
plan cannot be used on the RHC cost report, is this correct?
Ron?
Ron Nelson:
Well, the answer is while it will be part of
your total visits but it will be treated like an other or commercial
insurance, it will not be cost settled because River Bend is only
required and will only cost settle for those regular Medicare RHC
visits. So, the answer is that is correct.
(Bill Finerfrock):
Yes, I think that's one of the important things.
When a Medicare beneficiary enrolls in one of the Medicare Advantage
plans they have effectively removed themselves from the Medicare
program and are now covered by the rules and guidelines of that
private insurer. And as far as the RHC is concerned for your cost
report purposes they are not a Medicare beneficiary and would be
treated the same as if they were a commercially insured individual.
It also points out that there's some unscrupulous,
what they maintain are unscrupulous activities going on by agents
who are selling the plan which they're telling people to signup
for a prescription drug plan without informing them that they're
also signing up for a managed care plan along with that. And who
should they contact, and they contact their department of insurance
is one place and I'm just curious if this is a problem nationwide
and, if so, how is it being handled?
I've heard anecdotally of similar kinds of situations.
I can't say that it's something I've heard that I would characterize
as being systemic. But if you hear of that or if you have that,
let us know. I would also encourage you to contact your elected
officials, your congressmen and your two senators and make them
aware of what you believe to be unscrupulous marketing activities
by plans if you believe that that's occurring in your communities.
Operator, next question.
Operator:
Yes, we'll take our next question, please.
(Diane):
Hi, this is (Diane) from North Carolina. And,
in fact, you just read my e-mail, so I have no further questions.
And I'll leave the line open for the next person.
(Bill Finerfrock):
OK, thank you, (Diane). Next question, Operator.
Operator:
And we will now move on.
Mary Peterson:
Mary Peterson, (Mileblus Clinic), (Moston), Wisconsin.
(Bill Finerfrock):
Hey, Mary.
Mary Peterson:
I guess when you, you know, we really truly don't
negotiate a fee for service plan on paper, but you certainly are
going through all the hoops, practically, because you've got to
tell them how they're supposed to pay you. And you end up in a negotiation
even though you don't have a contract. And then once that happens
you're constantly auditing to make sure they're paying you the way
they're supposed to pay you, which nine out of ten times does not
happen correctly.
So, you have about as much scrutiny as you do
as when you are doing a contract, and one of the things, we have
a HMO Advantage plan here. And I'm not sure if the implication was
that there were no HMO managed care plans or if you were encompassing
them with the PPO when you're discussing PPOs? But there certainly
are Medicare Advantage plans that are HMOs and more restrictive
than the PPOs.
Ron Nelson:
Mary, that's a unique situation to Wisconsin
and just a few states where there are actually HMO. In fact, the
presentation that we had in Washington this week, I think they actually
referenced that there were very, very few actual HMO plans. And
Wisconsin is one of the states that does have a fairly high penetration
of what I would categorize together the regional PPO and within
that might also be the regional HMO or a local HMO plan. So, there's
no question, I know that you have those there in Wisconsin, but
it is also unique to the Wisconsin area.
Mary Peterson:
And then I have one other question, I know we
had talked previously about some kind of meeting of the minds with
CMS and these Advantage plans and perhaps the National Association
about payments correctly or educating them. And I talked to a (Frank
Suflinski) this week as a result of the rural health call, he's
CMS out of Denver.
(Bill Finerfrock):
Right.
Mary Peterson:
I mentioned that to him, and, you know, I really
think there has to be done - we, no matter what plan we get we're
educating them. We now have three fee for service plans and we,
and they started with 2004 with them and we're still not getting
paid. I mean it's a constant battle.
(Bill Finerfrock):
Right. I have spoken with Frank, and when he
and I spoke he was, he felt that it was a good idea, as well. Unfortunately,
the people who do the plan relations have not been as easy to deal
with in terms of working with us to try and set something up. But
we still are interested in trying to do that and get a handle on
what the plans are and what they know. Our first caller, (Jerry
Payne) was one who has had conversations with us. They've endeavored
on their own to try and better understand the RHC program. Some
other plans have done that, but there are others who don't seem
to care too much whether they learn a lot about RHCs.
Mary Peterson:
Well, I think what happens is the local reps
that we deal with sort of try to get, understanding what's going
on, but it has to get, somehow it has to either be programmed into
their computer systems or whoever is paying the claims has to understand
what's going on. And, you know, we would love to do this by sending
a manual claim alerting them it's a rural health clinic claim, but
they want to get them into their automated system which I think
is faster, only to turnaround and we're paid wrong, and we're dealing
with it back door. So.
Ron Nelson:
Mary, I'd just like to suggest, also, I actually
sat at the table this past few days with a representative from Wisconsin
who seemed to believe that things were really going well with the
contracting with rural health clinics in Wisconsin. So, you may
want to make sure that your hospital association and other organizations
are aware of some of the problems that you're having in terms of
payment adjudication, because it is clear and we're hearing it across
the country that plans don't necessarily, while they've now figured
out how to put together a proposal that doesn't necessarily mean
that the back shop activities or the administrative activities of
processing and adjudicating and paying a claim correctly are happening.
Mary Peterson:
Right. Well, we have no contracts with our fee
for service plans, so it is mainly a process and a procedure that
has to be carried out correctly at the insurers, and that's what
we're continuing to try to deal with is to get that process to get
it right the first time.
(Bill Finerfrock):
All right. Thank you, Mary.
Mary Peterson:
Yes.
(Bill Finerfrock):
Last call, Operator?
Operator:
Yes, your line is open. Please go ahead.
Male: Hello.
(Bill Finerfrock):
Hello.
Ron Nelson:
Go ahead if you have a question?
Operator:
Hearing no response, we'll move on.
Ernie Parisi:
Hello, this is Ernie Parisi in (Clifton), Texas.
(Bill Finerfrock):
Hey, Ernie.
Ron Nelson:
Hi, Ernie.
Ernie Parisi:
How are you doing? My concern has to do with
the fact that all the Medicare Advantage patients are being lost
as Medicare patients. If you - the more penetration you get the
more loss you're going to have, which means essentially you're going
to lose all your cost based reimbursement if it goes 100%. And my
concern is, is whether or not the Association should take that on
as an issue because I mean essentially we could lose everything
we've worked for over the past years.
(Bill Finerfrock):
I guess we could debate. I mean I'm not, I don't
know that you'll ever see a situation where Medicare, regular Medicare
goes away and you have 100% representation by a private, of individuals
enrolled in private plans. But certainly the cross-over implications
are something that we've at least given some thought to, and what
are the long-term implications if more and more individuals enroll
in private plans?
Ernie Parisi:
I mean we can negotiate all the rates we want,
especially as they are right now, but the more penetration you have
in the Medicare Advantage plans the less reimbursement you're going
to get on a cost based basis, which means you're going to get less
payment on a continuing basis until it's gone. That's my concern.
(Bill Finerfrock):
Yes, I mean I don't - I mean, as you know, some
of the private fee for service plans are paying your cost plus a
little bit more. Whether or not we can assure that that's going
to continue, I don't know. I mean I know some of the folks in Texas
have looked at some of the programs and feel that what the private
plans are offering them is very reasonable and fair reimbursement
relative to what they were getting under regular Medicare, so I
mean I think it's something that we've got to keep an eye on and
watch. And then if we're successful at getting the wraparound, obviously,
that's another factor in there, as well.
Ernie Parisi:
Well, Ron, I appreciate the presentation. It
certainly was informative. And I certainly picked up something from
it. And I certainly do appreciate it. And thanks, again.
Ron Nelson:
Thanks. And, again, I think, Bill, before we
wrap-up it's important for those that are on the call to understand
the opportunity to gain additional information by attending that
conference March 9th and 10th in Texas and San Antonio.
(Bill Finerfrock):
Yes. And you can get - we will have representatives
of the plans there, we will have panel discussions to talk about
what they're doing, how they're viewing the RHC program, et cetera.
To get information you can go to the web site which is www.narhc.org
and you can sign-up to attend the conference online there.
You should have received a link to Ron's PowerPoint
presentation, so hopefully you all had that.
A transcript of this call will be available typically
it takes us a couple of weeks to get it back, get it cleaned up,
and get it posted, but a notification of its availability will be
sent out to the Rural Health Clinic technical assistance list serve.
I want to thank everybody for participating in
today's call and look forward to having you participate in future
calls. Thank you and we'll talk to you probably next month. Thanks.
Bye.
Operator?
Operator:
That does conclude our conference. Everyone,
we thank you for your patience. Have a great day.
END
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