Operator:
Good day, everyone, and welcome to the Federal Office of Rural Health
Policy and National Association of Rural Health Clinics conference
call. As a reminder, this call is being recorded.
At this time for opening
comments and introductions, I would like to turn the conference
over to Mr. Bill Finerfrock. Please go ahead, sir.
Bill Finerfrock:
Thank you. Welcome to the third in a series
of national teleconference calls being sponsored by the Federal Office
of Rural Health Policy and the National Association of Rural Health
Clinic. Today's call is on the annual evaluation for rural health
clinics.
Our speaker today is Jim
Estes with Healthcare Horizon Services. Jim will provide explanation
of the RHC annual evaluation required under the current regulations.
It will also include an outline of the annual evaluation requirements
so the participants will be able to conduct their own annual evaluation
and be prepared for a recertification site visit by your state health
department.
Today's discussion will
include policy and procedure manual review, chart review, review
committee makeup, utilization review, and more. At the conclusion
of Jim's remarks, there will be a 15-minute question-and-answer
period where you can pose questions and your phone lines will be
open and the Operator will provide instructions.
I want to thank the Federal
Office of Rural Health Policy for making this series possible and
providing the resources so that individuals can participate free
of charge and obtain this information. If you did not receive this
through the e-mail alert system -- the new -- the system we use
to put out the information, you can sign up to participate by going
to www.ruralhealth.hrsa.gov/rhc
and you'll be provided with a link.
In addition, if you have
questions, feel free to send them to info@narhc.org.
All questions and answers will be -- we'll make answers available
to them and a transcript of this call will be sent out through the
list serve probably within the next two weeks.
Jim, thank you for taking
the time to talk with us today and we look forward to your presentation
and it's all yours.
Jim Estes:
Great. Thank you, Bill. Being from Oklahoma,
I'm going to do my best to talk without the (Okie) accent. However,
I noticed on the very second slide after the first opening slide is
a top one presentation if you're following along, it says annual evaluation,
you got to do it. I should have said (y'all) go to do it.
There are a lot of clinics
across the nation that don't realize this is a requirement. In fact,
I run into folks all the time that have never performed an annual
evaluation of their rural health clinic. They just didn't know it
was one of the rules and one of the requirements. Now, when they
have their recertification visit from the state, then they discover,
to their sadness, that they're missing something as part of that
review process.
This report is an evaluation
of the clinic's total operation. It's something that's required
of all rural health clinics regardless of whether they're hospital
based, freestanding, owned by a nursing home, a corporation, a doctor.
It makes no difference
who the owner is: if you are a certified rural health clinic operating
under the Medicare program, even if you never bill Medicare. Let's
say you're a pediatric facility and you don't have any Medicare
disability kids and all you bill is your state Medicaid program:
you still have to comply with the Medicare rules of the Rural Health
Clinic program in order to continue as a rural health clinic. This
is what enables that pediatric clinic, for example, to receive their
enhanced Medicaid reimbursement by nature of being a rural health
clinic. Anything that you don't do that gets you out of compliance
with the rules puts you at risk of losing your certification as
a rural health clinic when the state comes by to perform their recertification
visit.
The annual evaluation
is not something that's expected at the initial certification because
you haven't been certified as a rural health clinic yet. But once
they come back with that re-certification visit, which can be every
year -- generally, I find it to be about every three years -- three
to five years, the Inspector will most likely ask for these evaluation
reports. I know of some states that are just really very lax in
doing those re-cert visits but you are liable -- you're open to
having a recertification visit any time the state chooses to come
by your part of the neighborhood and give you a visit.
So this is a report that
you need to have on file, either a separate file where you keep
it or put it in the appendix section of your policy and procedures
manual. You should have a policy in your policy and procedures manual
that stipulates you will do this. The policy should outline what
will be in that report according to the codes of federal regulation.
That's what we're going to go over more in-depth today and were
going to squeeze this in to a 45-minute -- now, a 40 -- 39-minute
context. But we'll make it, I assure you.
The annual evaluation
is required, as I said, to be in compliance, and in particular,
there are several different areas that you have to do. Every once
in a while, I'll insert where I'm at on the slide so you can keep
up with the PowerPoint. We're on number five at this point.
Basically, the regulations
state that you have to carry out or arrange for an annual evaluation
of your total program which includes review of specific areas, including
utilization, review of clinic records, and policies and procedures
among other things. Now, let's talk about what we mean by utilization.
Basically, you should
evaluate the numbers that you gather for your cost report. Every
rural health clinic should be able to get their encounters -- their
visits as defined by Medicare: medically necessary, face-to-face
visit between the patient and the provider, be that an NP, PA, CNM,
MD, or DO, in the clinic, in the patient's place of residence, or
in a nursing home. Those visits that you report as part of your
cost reporting process are the numbers that you need to analyze.
Look at them on a yearly basis. How many were Medicare, how many
were Medicaid, and how many are all other payer classes.
Now, if you want to go
onto more detail you can, but generally speaking, it's not that
critical to know which insurance companies you have more patients
with unless you're getting ready to negotiate a new contract with
them, in which case, you might want to run your report specifically
for each type of insurance company. Otherwise, the private pay,
commercial insurance pay, no pay -- sorry, those are still there,
always will be with us -- those types of visits--just kind of lump
together in the "all other category". The amount of detail
that you want to provide is strictly up to you. There's no stipulation
within the regulations as to how you look at the numbers, just that
you have to look at your numbers and see if utilization of the rural
health clinic is reasonable for the community where the clinic is
located.
This is a tool for you
to use more so than for the government to look at. It tells you
what your mix is on your visits re: does it still make sense for
your clinic to be a rural health clinic. I've had clients where
I would go in and do an evaluation of their program and find out
that, wow, they've only got 20-percent Medicare and Medicaid, and
of that, 15 percent of it was Medicare, only five percent Medicaid,
and the difference in reimbursement was negligible. They took a
harder look at it and in two cases in my experience, they've actually
decided no longer to be part of the rural health clinic program
because of situations in their state regarding Medicaid and other
issues that came into play, as well as this patient mix issue.
If you have more than
one location, you have to do an annual evaluation report for each
site. Every rural health clinic has its own provider number and
even if you might file a consolidated cost report where you take
all the costs from each of those clinics and combine them in one
cost report, the first page of that cost report will still list
each clinic provider number -- each RHC number that's contained
in those cost figures. If you have five rural health clinics in
that you own or that the hospital operates or the doctor owns (or
whoever), you have to have a separate annual evaluation report for
each site. It has to be there in that office so that when the inspector
comes by -- or at least within ready access where they can review
that report and see that you've fulfilled that requirement.
What is the review of
the clinic records? Well, this basically is a chart review. Now,
I realize a lot of rural health clinics are already doing chart
reviews, especially if you're part of a hospital-owned organization
that is participating in joint commission, a (JCAHO) or what is
commonly referred to as Jayco, where they have chart review as part
of their QA plan. As a rural health clinic, you still need to do
this no less than annually. In other words, once a year, you must
stop and do some kind of a chart review. Now, there's nothing in
the regulation that stipulates exactly what to look for but it makes
sense that you're going to look for the things that Medicare requires
for you to have in your chart.
On slide number eight,
as we progress through the PowerPoint presentation, you'll find
the beginning here -- at least, I think it's eight and nine is where
we have that listed, the outline of what can be considered typical
for a chart review. Obviously, you're going to confirm patient name.
Now, you know, that sounds
like -- well, of course, you've got the patient's name on there.
Well, sometimes it's a number and the name isn't revealed until
you open the chart. The name's not even on the outside of the chart
in some cases. I have found many times that we would have dictation
or reports or information filed in a medical record that did not
match the name on the chart. It may have been the brother or someone
with a similar last name. It's very easy to get things misfiled
when you're still with a paper system, so you're confirming the
patient name and that it matches everything else in the chart --
that this is all related, in fact, to this one patient that's listed
on the file.
Insurance class: you need
to know if they're commercial, private pay, Medicare, Medicaid,
self-paid, no-pay, whatever, and that class is usually revealed
by a copy of their insurance card or a copy of their Medicare card,
Medicaid eligibility (from your Medifax unit), or whatever you do
to confirm their current eligibility status with the Medicaid program
in your state.
Vital signs -- you know,
I asked some folks at Riverbend, one of the RHC Fiscal Intermediaries
(FI) some time ago if vital signs must be on an encounter report
or part of the notes whenever they ask for notes to confirm whether
an encounter was medically necessary. I asked them if those were
missing would that automatically void that visit as being eligible
to be counted as an encounter and paid a rural health encounter
rate and the response I got really kind of surprised me.
What the vital signs do
for them in their medical review, at least at the time I talked
to them was it confirms that the patient was actually physically
present, and in absence of those vital signs, makes them look at
little closer at all the rest of the documentation. Well, you know,
I don't know about everybody else out there today but I don't want
the government looking closer at me -- any closer than necessary.
Not that I'm doing anything wrong. It's just many times if they
start looking closer, they'll find something that you thought you
were doing right, and lo and behold, you weren't. You were making
an error. It's best -- it's kind of like having a tax audit. I don't
want them looking too close because if they look far enough and
deep enough, I don't know, I probably made a mistake somewhere.
Somebody's liable to find something.
The same is true with
your audit of the chart. Should it trigger a closer look by your
intermediary, then, as they look closer, there may be a host of
things that they'll have suggestions for you to change or correct,
which can be good as far as quality of care and working your program
but it can also be difficult if there's money involved. So my comment
about vital signs is, obviously, that needs to be part of the record
and if somehow you're recording those but it's not becoming part
of the permanent medical record, you need to change your system
and make sure that you have the vital signs in the medical chart.
Signature, there are some
specific requirements now from Medicare regarding signatures on
patient charts, on the notes themselves and on dictation. I know
a presentation at Riverbend made last year I believe at a national
level, a copy of their slide that I used in my presentation says
very clearly that initials will not be sufficient on medical chart
notes. They need a signature from the provider.
While initials may work
on your encounter form or on your internal mechanisms, when it comes
for dictation or actual patient notes, they need to have a signature
on them. And that brings us to the (soap) notes. Are they sufficient?
What do they say? Do they meet what you, as a reviewer, feels is
sufficient documentation to justify the level of coding that was
charged out for that day's visit.
Now, you may not always
go quite that in detail as far as pulling your remittance advice
and comparing what was charged out and billed to the intermediary
for that date and compare that to the notes. But generally, you
should look at the SOAP notes. First of all, are they readable.
If they're illegible, then, I'm sorry, it's not an encounter. In
fact, the October 2000 Federal Register contains an article from
the Office of Inspector General that makes it very clear that up-coding,
down-coding, and eligible notes are considered a form of Medicare
fraud.
So, if you've got providers
working for you that are writing in some unknown language that you
can't read, then your main emphasis here is they're putting themselves
in a position of having committed fraud, not only with a payback
of money but potentially other kinds of ramifications. They've either
got to learn how to write or dictate and pay for dictation transcription
services, or look seriously in electronic medical records so that
you get out of the handwriting business on the notes.
In any rate, if the notes
are there and they're readable, are they sufficient to justify billing
it as an encounter. What you don't want to see is a nurse's note
on the chart that says, "no problem, refill only" and
then the doctor's notes just say, "hypertension, fill meds,
see them in a year". That's not going to cut it. That's not
sufficient. The notes need to be documenting what they did; why
did that patient need to be physically present.
The way Riverbend puts
it in their local medical review policy LMPR regarding rural health
clinics is that they "lay hands on" the patient. What
required that patient to be physically present, what did the doctor
or the provider do that made it necessary -- medically necessary
for them to have that appointment.
So those (SOAP) notes
are very, very important. You should look at each date of service.
You can make that as detailed as you want to. If you've got a QA
plan going that compares orders for tests and then see if those
tests were actually performed and whether or not you have a record
of that in the chart, you can take it down that road if you want
to. What I am providing today is again, simply an outline of areas
that you might want to include.
Slide Number Six: patient
information; has that been updated, is there any notation on there
by the front office staff, their initials and a date, or something
that shows that they've confirmed with the patient that this information
is correct in their chart. A lot of times, there's a breakdown between
the chart and the computer system. They might correct it in the
computer system but not correct it in the chart and it's important
that you have the same set of information in both locations.
Consent form: this is
a consent to treat. There's a lot of different types of consents
and releases out there in the field today. At one time, "implied
consent" was considered sufficient. If the patient came in
and said, "I want to see the doctor", then it was assumed
they were giving that physician consent by nature of having asked
to see him/her. You talk to just about any attorney and they're
going to tell you that won't work in today's "lawsuit"
society. I do not have any clients that don't utilize a consent-to-treat
form and almost everyone I run into nowadays has it. Check with
your malpractice insurance and see what they think about operating
without something in writing that says the patient gives you consent
to provide them with medical care.
I know in some states
they require a special consent form if a PA or an NP is going to
be providing that service--the patient has to give their informed
consent regarding the use of the nurse practitioner or physician's
assistant. I know Texas used to be that way. I'm not sure if they
still are or not. But that's something that you may also want to
check into. Generally, that's not an issue as long as the consent
form is specific to your clinic and specific to the medical staff
of your clinic. It needs to be stated on the form that it is for
the "XYZ" (your clinic name) clinic and that it covers
the medical staff and employees of the "XYZ" (your clinic
name) clinic.
Many times when a clinic
is purchased by another organization or you sell to someone else
you continue with the same charts. In these instances, I find that
old forms are in place and they just assume that since the patient
gave consent and release (HIPAA , etc.) the first time around that
it still covers them. No. You need to get new forms signed if there's
been a change of ownership. These forms should reflect the new owner,
otherwise, the new owner has not received permission to treat or
release information or anything on that patient.
You also want to watch
for the patient that's no longer a child. If they turn 18, then
new consent forms need to be signed. New release of information
needs to be signed. Also, you've got to be careful that you don't
release information to mom and dad when they call regarding that
18 year old. You know, mom and dad may be paying the clinic bill
but we don't have any right to get the information regarding their
child's care because they're no longer a child; they're now an adult.
So you need to get new forms. A system to "flag" this
is helpful.
Now, I realize in some
states there are certain consent requirements, especially in the
area of STDs or in birth control and so forth. States differ in
the ages for consent to be able to be given by the patient so you
need to be aware of those differences and make sure that you're
covered on the consent-to-treat and release the information.
Item number eight is the
release-of-information form. This can all be on one sheet but you
have to have separate language for each type of consent/release,
HIPAA, etc. The patient may be signing once but all of the separate
language for each type of consent, release, etc. needs to be specific.
The most concise method I've seen is one that has it all on one
page so you don't have the patient signing 15 things every time
they come in.
Number nine: HIPAA notice
of the receipt of your privacy statement. This is the standard phraseology
that everyone's been doing now for a couple of years. I'm finding
more and more that clinics are beginning to get a little lax in
getting that notice signed by the patient, because they're at the
point now where pretty much everybody that's coming in has been
in since HIPAA went into affect and we had to get that notice receipt
signed by the patient. And so, as a result, the front desk is slipping
a little bit in many clinics in not confirming that it's there.
I've discovered a good
method for making sure your HIPAA form is in the chart. I have a
RHC client that has a little purple hippopotamus rubber stamp that
they've made. The first time I saw that purple hippo stamped on
the folder, I couldn't understand what it was for until they explained
it to me. "That means that our hippo form is in the chart."
So, basically, they took HIPAA, turned into hippo, and once they've
got it done, they stamp the outside of the folder with that purple
hippopotamus and they know that they've got the HIPAA form in there
and don't have to even check any further. It's a real quick flag
for them. Whatever system you use, you want to make sure the HIPAA
form is there.
Number 10 is the Medicare
lifetime signature language. That's not a specific form as much
as it is language that Medicare wants you to have for the Medicare
patient. It's a one-time deal. You don't have to do this every year.
It's just a one-time signature. Many times when the (physical) intermediary
asks you for notes regarding a date of service to confirm that it
was medically necessary and fits the definition of an encounter
-- many times, they will also ask for a copy of that patient's Medicare
lifetime signature language. So you need to make sure this form
is in the chart. The language for this requirement is available
at my web site: www.healthcarehorizon.com
Number 11 and 12: the
Rx log and the problem log. The decision on whether to not to utilize
these forms is up to the clinic. I realize we're taking a little
bit of time on this chart review piece but I've had an awful lot
of questions on this. They're 11 and 12 on slide number nine. If
you're a joint commission, you have to have these. If you're not,
there's no requirement to my knowledge for a problem log or a prescription
log. Now, obviously, you have to have somewhere in the chart where
you've made your prescriptions and what they were. Generally, that's
going to be in your (soap) notes.
If you want to keep a
listing of chronic meds, where you've made changes, increased dosage,
you know, lowered dosages, removed items from the list, that's fine.
If you want to have a log for problems that would list everything
they've ever come in for, every appointment, that's your choice.
Or if you wanted to a chronic problem list, meaning asthma, COPD,
hypertension, diabetes, whatever that are ongoing chronic problems,
that's fine too but there's not a requirement for you to have that.
Now, you need to be careful. If your policy and procedures manual
says you're going to do this, then you better be doing it and you
better be doing it on every chart, on every patient.
Many times, I'll find
a client that has a prescription in a problem log and they're very
lackadaisical about getting it done, mostly because it's not real
clear in their policy manual who does it. Is the doctor the one
that writes enters this data? Is it his/her nurse that writes in
this information? Or is it the front desk -- who fills this out.
So if you're going to do it, your policy and procedure manual needs
to stipulate what it is and who enters the information. Are these
forms a listing of every time they come for problems, or is it only
a chronic problem, and if so, what does that mean and who puts it
there.
If you're not doing it
and your manual says you're supposed to then you'll be cited by
your inspector, or you could be cited by your state inspector as
being out of compliance with your own policies and that opens a
door you don't really want to have opened because it creates a problem
for you.
Number 13: the history
form, and 14, is it updated. Every medical chart should have a medical
history form that includes family and social history as well as
the medical history of the patient. Now, in the case of a pediatric
client, you're obviously not going to have much on the patient in
the way of history other than maybe some birth information as far
weight and type of birth and any complications. But their family
history is very important to have so that you know if there is a
history of cancer or hypertension or diabetes, so that as a pediatrician
or a provider of care to children you could watch for that.
Number 15: allergy information.
That's got to be prominent on the chart. Now, I've heard all sorts
of different requirements coming out of state inspectors. Some want
it on the inside, lower left-hand corner and in every chart they
want to have allergy stamped on it or a big red sticker. Personally,
I've not been able to find anything that stipulates where it has
to be other than it has to be prominent on the chart. And from a
malpractice perspective, you want it to be prominently displayed
on the chart to protect you in any possible litigation proceedings
that might come against you as a provider.
In my opinion, you shouldn't
have a sticker on the chart unless they've got an allergy. It's
kind of like the little boy that cried wolf. If every chart has
a red sticker on it, it ends up meaning nothing so put those on
the chart of patients that that have a drug allergy, writing in
what they're allergic to. Make sure that it matches back to the
medical history. Now, many times the patient will say they're allergic
to something when they're not and that's where the provider has
to figure that out and make note of it in the chart.
For example, a patient
may say they're allergic to aspirin. Maybe in reality, they're not
allergic to it. They just don't tolerate it well. It upsets their
stomach. Perhaps that's the thing. But they consider that allergic.
Well, the doctor maybe doesn't consider that an allergy. That's
just an intolerance of a particular medication. So what it says
in the medical history that the patient fills out sometimes may
not match what is shown on the chart as far as their allergies to
medications. If it doesn't match, then you want to make sure that
there's documentation as to why it doesn't match. The provider must
make that determination that that was an error on the part of the
patient or that they really didn't understand the question.
No-shows are noted. This is a litigation issue. It's not a federal
requirement to my knowledge that you have to have no-shows documented
in the patient's chart and I get asked this question a lot. In my
opinion, it's a good idea. The patient does have responsibility
for their health care. Should you have a lawsuit placed against
you for malpractice of any kind, it can be very helpful to be able
to prove in court, either through no-shows noted in the chart or
in a computer system by patient where you can print out the schedule
of appointments they kept and the ones they didn't, where you can
show, look, we made these appointments and they didn't show up.
They didn't call and cancel. They just didn't make their appointment.
That shows that you have done your part in establishing the appointment
and that the patient failed to follow through. So those no-shows
are important things to document in some way.
Now, one thing that's
not on here, before the comment number 17, we should have MSP, Medicare
secondary payer questionnaire. For the Medicare patient that form
should be somewhere. If not in the medical chart, it needs to be
in a separate file, but you should have that form. Technically,
it depends on the FI how they interpret this, but my understanding
is that technically the patient is supposed to sign something that
indicates that Medicare is primary, that there's not someone else
that's supposed to be paying for that particular office visit, on
every appointment. Specific questions about MSP can be answered
through your FI's Website, whether that be -- Trailblazer or Riverbend,
Trispan or any of the other (many) FI companies handling RHC claims.
In particular, I know that the Riverbend website has specific information,
including the questions that are supposed to be asked, in their
MSP section of their Website. This site is: www.riverbendgba.com.
Number 10: You need to
include in part of the annual evaluation a review of the clinic's
policies and procedures manual (PPM). This review must be done by
the medical director, as well as the PA, NP, or certified nurse
midwife, and the office manager. All these people should sign off
on the annual evaluation report that results from all the areas
we've been talking about so far. The purpose of this evaluation
is to determine whether the utilization of services was appropriate
and that you were actually following your policies and procedures
and then any changes that need to be made in those policies.
Slide 12: we're talking
about the staff considering those findings and taking corrective
action if necessary. In other words, if you conduct an annual evaluation
and say something like, "our policy and procedure manual needs
to be changed on page 47, section whatever regarding medical records
in that we no longer utilize a problem log or we have added the
HIPAA security notice as one of the forms that must in the chart".
Well, that's fine for
you to make that recommendation but if you don't actually follow
through and do it by changing the policy manual, updating it, then
it was pointless and that would be possible grounds for an inspector
to say, wait a minute, now you're not only out of compliance with
not having the form but you're out of compliance with your own recommendation
from the annual report. You haven't done what you said you were
going to do.
There are specific requirements
as to who must be included in the group of clinic employees and
governors that sign off on this annual evaluation and that needs
to include someone who is not an employee of the clinic.
Slide number 15: A brief
outline of what would be in the annual evaluation. I noticed earlier
today, I made an error on this slide but it's OK. We're stressing,
like in any good business, location, location, location, I guess.
The overview of the rural health clinic: that would be analyzing
your location, the scope of practice, the services you are providing.
Just a simple paragraph that states here's what we're doing here.
And then two and three: location, location; where are you located
what counties do you serve, what's your market area.
Disclosure of ownership
is important in that you need to be able to stipulate in this section
that the clinic is still owned by the same entity, individuals,
etc. as last year. And I apologize. I used the word midlevel and
Mr. Finerfrock does not like me to use that word and I've got it
in that slide. I really thought I took out all "midlevel"
references to these medical professionals . Midlevel, meaning your
nurse practitioner, your PA, or certified nurse midwife. So if I
offended anyone with that, I do apologize.
Item number six on slide
number 18: the definitions that you use in the report. This isn't
a requirement but this is something that I use in my reports. This
can be helpful especially for that person that is not a staff member
that's going to review this report and sign off on it. You may be
using acronyms that are unfamiliar to a non-medical person.
Now, that non-employee
that you have on the Annual Review Committee could be the pharmacist
in town or the pharmacist's spouse, your pastor, your pastor's spouse,
etc. It can be difficult for them to understand all of the words
in the report and it doesn't make sense to have them sign off on
something they don't understand. So you might or might not want
to use the definitions or have some sort of short glossary included.
Now it's time to review
the encounters by type. That's the utilization report that we talked
about earlier: Medicare, Medicaid, and all other. You can find out
some fascinating information about your clinic by doing this on
an annual basis. I have conducted Annual Evaluations for some of
my clients for several years in a row, and its really fascinating
to see how the patients types have shifted, especially if they had
more than one location. It helps to go back and analyze why did
we have a drop in our Medicare population visits during that year,
why did we have such a dramatic increase in our Medicaid business
during that year, and see what we were doing good and bad. Again,
evaluating the total program. Taking a look at the whole picture
and seeing where you're headed and where you've been.
Number eight: CPT coding
analysis. It's not a requirement, but it certainly is a smart thing
to do. This is an excellent report for analysis provided your software
can generate the report. This is generally a "productivity
report" by CPT code--by provider so that "Doctor X"
report provides his or her visits by Medicare, Medicaid, and all
other. You can combine data on physicians if you want or you can
break them down by type and physician, but do it by CPT code.
For example, I have a
lot of physicians that will tell me, I never, never, ever use 99211
in my clinic. Then when we run this report off the system, they've
got 248 visits listed under 99211 and I ask them, "where did
that come from?" They respond, "Well, I don't know. It
must be my nurse using my number." Well, if that's true, they've
got a bigger problem than was originally thought because if the
nurse is entering information into the billing system under the
medical provider's number, then most likely claims are being submitted
under the assumption that the medical provider provided a service
when in reality, the service was a "nursing service" only,
and not billable as an encounter.
The E & M code 99211
is not a billable code for the rural health clinic. It is a nurse-only
service and you don't know if it's being used until you run some
kind of productivity analysis off of your system. So it's very important
from a management perspective that you do this analysis, plus you're
able to tell if you've got providers that are doing everything as
a 213. If that's all they've got is a 99213 for 99% of their visits,
oh, come on, you know, that's not realistic. You're not going to
have all the visits at the 99213 level of service. That tells me
that that provider is either being lazy or they just don't understand
coding and they're just putting everything as a 213. The level of
care provided and documented in the chart notes must justify the
level that is billed.
All encounters simply
cannot be the same level of service in a rural health clinic. You're
going to have some 99214 and 99215 and a few 99212. Granted, 213
may be the most prominent code but it's not the only one. The only
way you can find it out is to run that kind of an analysis. An annual
evaluation is a good time to do it but it is not a requirement by
the federal rules.
Number nine on slide number
19: cost analysis by category. This is a good time to look at the
cost report and go back and look a little closer at it. I realize
a lot of hospital-based programs don't share the cost report with
the folks out in the trenches in the clinic, that it's a hospital
administration issue and many times they don't even communicate
to the providers or to the office manager anything to do with the
cost report.
I believe that's a serious
error on the part of the administration. The office manager and
appropriate staff in the RHC should be involved in the cost report
process especially in the area of collecting/verifying the numbers
for the visits. It may be that the cost side of the cost report
is not an area where the RHC manager even has access to the information,
especially in a hospital-owned environment, but still, you need
to confirm that the visit counts were correct, that they looked
right compared to what the RHC manager knows it to be by being in
the clinic every day, and then you can do an analysis of the cost
to see how it fits with the overall operation of the clinic.
Number 10: is a statement
of the scope of practice. Really, that fits into the overview section
that we had earlier, just listing the services you provide, and
any changes you may have made in the previous year.
Perhaps you've decided
this rural health clinic's no longer going to provide x-ray services.
X-Ray services are generally a money-losing service in a RHC. These
cost of these services is not an allowable cost in the RHC cost
report because it's a diagnostic test, so the RHC decides to get
out of the x-ray business and just send them across the street to
the hospital (or wherever). Well, you need to make a note in your
annual evaluation that you have changed your scope of practice,
in that you no longer provide x-ray services to your patients.
It also stands to reason
that if you have changed your scope of practice by adding or deleting
particular services, then your policies and procedures manual will
have a change that year, reflecting the change in your services.
Number 11: the review
of your policy and procedures manual. Some sort of report that indicates
that a review was conducted by specific people and specific staff
members and this non-staff person and here's what we found that
we need to change and correct or update on it.
Number 12: on slide number
20, a listing of those on the review committee, their names and
titles. Then signatures of that review committee; every one of them
signing off on that evaluation report.
Item 14, Slide 21: recommendations
for changes and improvement. In other words, we recommend that we
do "blank". An example would be: you discovered during
a walk-through of the clinic that there were no evacuation plans
posted. Well, the reason for that was they repainted the walls two
months ago and somebody just forgot to put them back up.
I admit, those evacuation
plans are one of the dumbest things that's required. Who's going
to stop and look at a burning piece of paper on the wall if the
building's on fire. You're going to go out the nearest door. But
you must have the evacuation plan posted. So that might be something
that you would have in this section. Or maybe you haven't had a
fire marshal's inspection in three years and you discover that as
part of this annual review. Then your recommendation would be to
get the fire marshal in and conduct the inspection that's required
to be done on an annual basis.
Number 15: a timeline.
In other words, you're saying that all these recommendations are
going to be completed by a certain specific date so that you can
then (on item 16, slide 22), you confirm those changes have been
made and the medical director then signs off on this annual evaluation
report.
Operator:
Pardon the interruption. There are five minutes
until our scheduled question-and-answer session today.
Jim Estes:
Thank you, Operator. And we're just about to
that point. How about that?
The annual evaluation
is a great opportunity to conduct an inspection of your clinic.
Now, is this a requirement of the annual evaluation report? I've
not found any regulation or memorandum that requires a facility
inspection by the clinic staff, but, boy, it sure is a good time
to do it. You can get so busy in your rural health clinic with the
daily operation of just getting the bills paid, getting the patients
taken care of that you overlook important facility and safety issues.
I've talked to a lot of
folks who said "we could get so much done around here if it
wasn't for these cotton-picking patients coming in all the time".
Well, of course, without them you wouldn't be in business and we
know that. But by the same token, it can be very, very hectic in
that clinic. As a result, you tend to forget things. Things get
missed. An inspection similar to what the state inspector will do
of the facility, not just the policy manual and the charts, but
actually going through the building and looking at the things that
they look at is very valuable and often reveals problems that you
don't even know exist.
Here's an example of what
I mean. One of my clients had me conduct their third consecutive
annual evaluation. They had hired a new provider and this provider
just insisted on being able to do a certain thing that really no
one else knew she was doing. She was keeping a stainless steel container
underneath the sink (with no locks on it). That container had detergent
-- cleansing material in it -- liquid -- along with the speculums
that she would use during the day, that she would just toss in there
to soak.. And next to it was the powdered detergent cleaner, disinfectant
that was next to it. There was no lock on the cabinet. Any kid could
get into it quickly. Besides that, that's not the place to put used
speculums. Not under the sink in the exam room.
The office manager had
no idea this was happening until I came in and did the walkthrough
and I took her by the hand said what is this. And she had a fit.
Well, you know, these things happen. More typical is the staff not
keeping a log of medicine samples given to patients, if that's required
by your state regulations that you log your samples in and out.
Or, perhaps the nurses are not dating and initialing those multiuse
vials or those clini-sticks for the UAs; those types of things that
need to be dated when you first open them. Perhaps that's not happening.
Perhaps you've got outdated
supplies or drugs in the building. Maybe your crash box that you
have for your emergency response, which is a requirement of the
Rural Health Clinic. Maybe the drugs in there are two years old
and nobody ever bothered to look. Well, you can't have outdated
(Epi) and (Beni) and anticonvulsants and old, brittle airways. Perhaps
your oxygen tank's empty. Sometimes you don't see this unless you
stop and walk through the building and do it like a state inspector
would do. That can reveal a lot of extra areas that you might want
to look at closer and can in fact become part of your QA program.
Now, real quickly -- I
see I've got two minutes left before we go to questions -- this
report -- this annual evaluation process is a requirement for this
year for 2005. It sounds like it's going to be a requirement for
'06. The best we can tell about the final regulations from the Balanced
Budget Act of '97 that they're rescinding and reprinting is that
it will not take affect until sometime in '06 on the new regs where
we get the QAPI requirement coming in, which will do away with the
actual annual evaluation report. Not all the components but the
report itself.
For now, if you're rural
health clinic in 2005 and it looks like any portion of 2006 is your
fiscal year, you will have to do the annual evaluation report for
this year and for '06. Then you can stop and delve into the QA PI
mess that will be coming our way eventually.
With that, I come to my
last slide that says questions before the thank-you slide.
And Mr. Finerfrock, I
think we've got maybe 30 seconds before question time anyway so
it looks like we're about there.
Bill Finerfrock:
Yes, we're right about there. Thank you, Jim,
for your presentation. It was extremely helpful and certainly for
me and (hopefully) for the others who were on the call.
At this time, what we
would like to do is we will open the phone lines for questions.
The Operator -- I'll turn it over to the Operator and she will let
you know how you can ask a question. So Operator, if you would give
the instructions on how to ask a question and when you -- when your
line is opened up, if you would give us your name and also where
you're calling from.
Operator:
Thank you. The question-and-answer session
today will be conducted electronically. To ask a question, please
press star one on your touch-tone telephone at this time. Again, that's
star one for questions. We'll take as many questions as time permits
and proceed in the order that you signal us. A voice prompt on your
phone line will indicate when your line is open to ask a question.
Please state your name before posing your question. And once again,
it is star one. We'll start with our first question.
Sue Morris:
Hi. This is Sue Morris (from) Hickory Flat,
Mississippi. A question please about the consent forms that you were
talking about. How often do you need to have a new consent-to-treat
form signed? (i.e.), this practice has been in operation 20-plus years.
Do you ever need to have a new consent to sign for that patient?
Jim Estes:
I'm not aware of any change in the language
for that consent-to-treat. If you've had the same ownership for 20
years, there's not been a change, then the original consent-to-treat
is fine unless that language says specifically Dr. Jones, and now
it's Dr. Jones' son that runs the practice. It depends on how it was
worded when they originally signed it. So that's the best answer I
can give you for that, Sue.
Sue Morris:
Thank you, Jim.
Operator:
Moving on, we'll now take a next question.
(Mike Shumaker):
Jim, (Mike Shumaker), Park
City
Jim Estes:
Yes.
(Mike Shumaker):
... Park City, Kansas.
Jim Estes:
Yes.
(Mike Shumaker):
Hey, Jim, on the signatures
for the physicians, I've got a program memorandum from Department
of Health and Human Services dated March 28th, 2003. What it states
is in regards to the signature, ((inaudible)) may include written
signatures, initials, computer (fee), or other code.
Jim Estes:
Signatures on what? The medical chart notes
or the claim?
(Mike Shumaker):
On the progress note,
on the (soap) note.
Jim Estes:
OK, what I'm basing my comment on is presentation
from Riverbend stipulated a signature that initials weren't enough;
the stamp was not enough. Now, on the claim ...
(Mike Shumaker):
Well ...
Jim Estes:
... that's another story.
(Mike Shumaker):
... well, actually, I
talked to Bill about this a couple of years ago because we had some
issues with Riverbend in regards to this and it is our understanding
that on the dictation the patient or the physician's name is typed
out completely, for instance, R.W. Yoakum, and it is our understanding
with this memorandum, he can initial that.
Jim Estes:
I will double check my source and make sure.
My wife tells me I've been wrong before so it could be that I'm incorrect
on that one.
(Mike Shumaker):
OK, that memorandum is
March 28 of 2003.
Jim Estes:
Yes, it could be (there's) something more recent
than that but I'll double check.
Bill Finerfrock:
(Mike), do you have the program memo number
there?
(Mike Shumaker):
Let's see, it's CMS publication
60A. I don't know if that'll help you or not.
Bill Finerfrock:
60 or 16?
(Mike Shumaker):
60A. The transmittal,
would that help you at all?
Jim Estes:
Yes.
(Mike Shumaker):
A03021.
Bill Finerfrock:
OK.
Jim Estes:
OK.
(Mike Shumaker):
Thank you.
Bill Finerfrock:
Thanks.
Jim Estes:
We'll confirm it.
NOTE FROM JIM:
Following the session I contacted Cindy Geren with Riverbend with
the following e-mail.
Here's a copy of that e-mail and her response:
JUNE 14, 2005
Cindy:
The memorandum in question
is Change Request 2511, Transmittal A-03-021.
Among other things it has a section: "RHC/FQHC Guidelines for
Signature and
Documentation of Medical Records" on the next to last page.
Specifically this says
"...the identification may include written
signatures, initials, computer key or other code" in reference
to
authentication in a method established to identify the author.
What I'm getting out of
all this (besides a headache!) is that as long as
the clinic has a signature/initial verification page in their policy
and
procedure manual that clearly established authentication of the
signature/initials of the medical provider, then perhaps initials
on
dictated and other medical chart entries would work?
The last paragraph of this
memorandum says "For example, stamped signature
need not be countersigned or initialed by the provider. This would
negate
the expediency of using a stamped signature. Neither should unsigned
dictations be accepted as an acceptable practice"
So, now I'm really confused.
I'm still gonna teach "sign the dictation, notes, etc.",
but I do see where folks can get the idea that a
stamped signature is alright, provided you have the appropriate
policies in
place, and that initials are acceptable, provided you again, have
the
verification/authentication policies and pages in place.
What Say YE??? Jim
Jim - After digesting all the info we have, including the CR you
quoted
below.....I see no changes to what Dr Duval published in the LMRP
for RHC.
The paragraph you quoted from the CR pertains to electronic medical
records.
We also have that noted in the LMRP. I agree with you.....SIGN the
records.
Cindy
Now, back to the questions
and answers:
Louise Rumor:
Hi. My name's Louise Rumor.
I'm from the Village Clinic in Chiloquin, Oregon. We're a new rural
health clinic. We received our certification in November of 2004.
When -- at what point am I required to do this annual evaluation?
Jim Estes:
According to the rules, as I understand, it's
got to be within 12 months of your certification date. Generally,
everyone does it once within their fiscal year so you're looking at
November of '04 when you became a rural health clinic. You need to
do one sometime before November of '05 and then again before November
of '06. I know at least it'll go that far but it is 12 months.
Now, you don't have to
do it all at one time.
Louise Rumor:
Right.
Jim Estes:
If you want to do part of it -- you know, part
of your report at a particular time of the year and then finish out
the rest of it later that's fine, but generally, it's easier just
to do it and get it over with and file it away. Within 12 months of
your certification date and then 12 months thereafter.
Louise Rumor:
Thank you.
(Steve):
Hi. This is (Steve) from
Michigan and I wondered whether it would be possible to get this
presentation on some sort of recording that we could then work with
our other rural health clinics to listen to and watch your wonderful
presentation online.
Bill Finerfrock:
In terms of the video, we've looked at various
options. Video is not only cost prohibitive but the technology of
the bandwidth that is available in different communities makes it
impractical for a lot of folks. It also is cost prohibitive to do
a audio recording and keep that posted.
What we will do is make
a transcript of the call available and this is all being transcribed
and we will then, once we get the transcription, get that to Jim,
have him go through it to make sure that it accurately reflects
what was said, and then that will be posted on the NARHC Website
as well as the ORHP Website and individuals can download the transcript.
This series, as I mentioned,
is being funded by the Office of Rural Health Policy. There will
be -- hopefully this will be continued next year through the funding
process. Certainly looking at recording or perhaps building that
into the budget but at this time there's not money in the budget
to pay for this call to be recorded and kept online.
(Steve):
That makes -- that makes
great sense. So we could download it and burn it to a CD and share
that CD with our rural health centers and let them go to your site
and read that and watch on the Internet?
Bill Finerfrock:
There is -- well, no. Right now, there is no
watch capability. We've used the simplest technology, which is just
a phone technology because that was the one thing we knew that everybody
would have access to.
(Steve):
I just mean the PowerPoint
that we just all watched. I was sitting here going along clicking
on PowerPoint and going through a slide.
Bill Finerfrock:
The PowerPoint is up and available for anybody
to download.
(Steve):
Good.
Bill Finerfrock:
A transcript of this will be also available
for download.
(Steve):
OK, so the PowerPoint
will exist and you'll send a CD out with his comments and then we
could -- we could ...
Bill Finerfrock:
The transcript will be a written transcript
...
(Steve):
OK.
Bill Finerfrock:
... be available for people to download and
read.
(Steve):
OK. All right. I can --
OK, I got it. Thanks.
Operator:
As a reminder today, it is star one for questions.
And we'll move on to our next question. Caller, your line is open.
Tom Martin:
Yes, this is Tom Martin from North Basin Health
Services in Davenport, Washington, and I have a question regarding
the non-clinic staff member on the review committee. Can that individual
be in a corporation that owns the clinics, a member or a staff member
from another division, or does it need to be an outside party?
Jim Estes:
You know, I've heard different interpretations
of that and I've never heard the state inspector having an issue with
that part of an annual evaluation. Normally, they're just thrilled
that you got the report in there at all because it's so often that
the folks don't do this.
It is important that they
not be on the staff of the clinic; staff who's cost is in the RHC
cost report, if you follow me. If they're not a staff person that's
paid through the cost center of the rural health clinic, I believe
you should be OK there. If you mean an employee of the "mother"
corporation, you know, you're talking marginal and it's going to
be up to the interpretation of the individual state inspector as
to whether or not that will fulfill the non-staff person requirement
because there can be a huge corporation that owns the hospital who
may be Columbia or Tenant and it's someone from another city that
happens to be there and they utilize them as the non-staff person,
they have no contact with the clinic, they have no inherent interest
in the clinic, there's no conflict of interest in any way, they're
not paid out of that clinic's cost center, I don't see why a state
inspector would have an issue with that.
Tom Martin:
So it's more a conflict of interest issue than
anything else?
Jim Estes:
What they're wanting is to have someone that
is removed from the day-to-day operation of that clinic take a totally
open and unbiased look at that report and agree with it or disagree
or maybe point out something that someone else couldn't see because
they were looking at the trees instead of the forest or vice versa.
You know what I mean? They're wanting an unbiased, unconnected opinion
person on that panel that reviews the report.
Tom Martin:
Great. Thank you.
Operator:
Moving on, we'll now hear from -- caller, your
line is open. Hearing no response, we'll take our next question.
(Mary):
Yes, this is (Mary) from
Iowa and I have a question on the policy and procedure book. We
have a lot of our policies online so that we view them, you know,
online. We can print but would we have to print to make an actual
manual?
Jim Estes:
You know, that's a question that I'm not real
sure I can answer because it's fairly new. I mean it wasn't that long
ago that we were sitting at the typewriter with carbon paper...
(Mary):
Right.
Jim Estes:
... to make these manuals up. The fact that
you have it and it's accessible to your entire staff and a reviewer
could look at it and see that everything is in there that needed to
be, I believe would be sufficient. Now, some states require you to
submit a copy of your manual to the state licensing organization prior
to any certification visit or recertification visit. So it could depend.
I don't believe Iowa does that.
(Mary):
I guess not.
Jim Estes:
They don't have to actually see the manual
before they get there ...
(Mary):
Right.
Jim Estes:
... but some states do. So it would be one
of those situations where if the inspector comes in and says I want
to see your manual and you show them where it is online and they say
that's not sufficient, just print it off.
(Mary):
OK, and then a comment
on the MSP. We do have ours online. It worked great.
Jim Estes:
Now, you're part of a hospital group?
(Mary):
Yes.
Jim Estes:
OK, that's pretty common for a hospital-owned
rural health clinic. They know what the MSP is because it's part of
the Part A requirements at the hospital. In order to register as a
patient at the clinic, you must go through the MSP section. I mean,
you can't get past it.
(Mary):
Right.
Jim Estes:
... without completing it.
(Mary):
Right.
Jim Estes:
It's in the freestanding clinic that is not
owned by a hospital that many times they don't even know they're supposed
to do Medicare secondary payer questionnaire. So in your case being
online as part of the registration process is very common, it's very
typical, and it's excellent. It's a great way to do it.
(Mary):
Thank you.
Bill Finerfrock:
I had -- Operator, before we go to another
one, I had two questions that were submitted online.
One is from (Louise Levholt)
who asks: we're looking at electronic medical records. What type
of requirements will there be for the chart audit to comply with
rural health? We want to go paperless.
Jim Estes:
I use the same chart audit requirements with
clients that are on EMR as those that are on paper, in that I will
take random -- and I'm sure glad she asked that because I didn't put
this in there. You must do a chart review that includes closed and
open charts and it has to be a representative sample, meaning, if
you've got five providers, you're going to need to take charts from
each provider.
I would say, depending
on the clinic's encounter volume, it would make a difference as
to how many number-wise you're looking at. I do the same thing with
EMR, in that I randomly select certain charts and go in to make
sure that forms are present even if it's a scanned document. Many
times a consent, release and that type of form is a scanned document.
It's not actually part of the database. They fill the form out,
scan it into the system, and there it is. Granted, the patient notes
are typically electronic but a lot of the other things can be scanned
documents. So I don't see any difference between EMR and a paper
chart as far as what you look for in a chart audit.
It could be easier with
EMR because there are some things, depending on what system you've
got, that the doctor or the provider can't close that note until
they finish that note and it won't let them close until everything's
done that needs to be done. So there can be a great advantage there
from an audit perspective if you've got EMR. Many auditors will
go a lot faster along that part of the process during the inspection.
Bill Finerfrock:
The -- go ahead and open the lines, Operator.
The next one was actually a billing question and I don't think it's
necessarily appropriate for Jim. So, if we have any other online questions
we can get to before we run out time, let's try it.
Operator:
Absolutely. We do have quite a few callers.
Your line's still open. (And) we'll move on to the next question.
(Jody):
This is (Jody) from Iowa.
My question was already answered regarding the consent form. Thank
you.
Operator:
Moving on, we'll now hear from another caller.
Harold Curtis:
This is Harold Curtis
from the state of California. I had two questions.
One was: there was a Website
that was given at the beginning of the presentation which I only
got part of. I was wondering if I could have that again. And the
second question was dealing with the rural clinics. How much leeway
are they going to have with the evaluation when it's quite possible
that a lot of them may not have the infrastructure in place to carry
this out completely?
Jim Estes:
By leeway, you're meaning how much flack will
the state inspector cut you if you don't have that report?
Harold Curtis:
Exactly.
Jim Estes:
Well, I wish I could give you a hard and fast
answer on that.
My understanding is it's
a requirement in certification, so technically, they could say you're
no longer a rural health clinic because you didn't do it. I've never
heard of that happening. Most -- 99 percent of the state inspectors
that I've dealt with, and I've got clients in 45 states -- 99 percent
of them are not there to put you out of business or to shut you
down. They are there to make sure you're in compliance with federal
and state regulations. And many times before they leave, they'll
say, you know, if you'll do this right now, we won't even have to
write a citation and make you correct it. If you'll correct it with
me standing here, we'll consider it a done deal. I mean, that's
just how cooperative most of them are.
Now you get the rare occasion
when they get a burr under their saddle, as we say in Oklahoma,
and they'll ride it until the horse dies. I mean, they can just
get really upset about what would seem to be insignificant things.
Obviously, if you haven't done the report, you can't go back three
years ago and do it because it's time-sensitive. You're looking
at it now-"real time". It is a snapshot: evaluating your
program today for this time period. You could go back and reconstruct
some of it but, I mean, how can you evaluate your policy manual
from three years ago and see about any changes. It's not -- you're
not back three years ago. You can't go back in time.
So my comment would be
do it, do it now, assign someone to do it, hire somebody to do it,
but get it done. It really shouldn't be that big a deal as far as
the infrastructure and ability of someone to take that on and do
it. It's a project that should take a portion of a week of someone's
time if they're going to devote part-time to it; otherwise, you're
talking about a day that they ought to be able to get this completed.
Bill Finerfrock:
Operator, my clock says that we're up on our
time here.
So Jim, if individuals
have questions that they would like to submit, would you be willing
to respond to questions people could submit to you directly?
Jim Estes:
Absolutely, and that gentleman wanted to know
that other Website. If you could tell him that it will be posted somewhere
because it was kind of a long-handled one that you gave at the beginning.You
want to give your e-mail before I do that?
Jim Estes:
My e-mail's on the first slide of the presentation:
E-mail: hlthcarehorizons@mindspring.com
Website: www.healthcarehorizon.com
Bill Finerfrock:
All right. Very good. The e-mail address that
I -- or the Website address I had given for any individuals, if you
want to sign up -- if you're not signed up as part of the list serve
where we send out information, we send out the slide, we will send
out the transcript, if you go to www.ruralhealth.hrsa.gov/rhc
that takes you to the Federal Office of Rural Health Policy's Website
and you can click on there and it'll take you through the registration
process. All we're asking is for your name and your e-mail address
so we can communicate.
As I mentioned earlier,
this series is sponsored by the Office of Rural Health Policy in
conjunction with the National Association of Rural Health Clinics.
This is the third in the series. We are planning six calls. The
next one will be in about six weeks and I'm hopeful that it will
be on cost reporting issues for rural health clinics. We will get
information out on that as those details become more firm. Any comments
that you'd like to submit with regard to this series, please send
an e-mail to info@narhc.org.
We appreciate everyone's
participation today. We hope you found it very helpful. And again,
thank you to Jim Estes for giving of your time and expertise in
assisting folk with today's program.
We look forward to your participation in the future and we will
be in contact with you. Thank you.
Operator:
Once again, that does conclude today's conference
call. Thank you all for your participation and have a great day.
END
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