Updated: 3/2/2006

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by Healthcare Business Specialists

Welcome to the Healthcare Business Specialists home page dedicated to Rural Health Clinics (RHCs).  We have designed this site to provide the latest information on rural health clinics and information on Rural Health Clinic Update and RHC Boot Camp seminars. The seminars cover Medicare cost reporting, billing, annual evaluations, certification, and the operation of  RHCs as certified by Medicare under Public Law 95-210.  We hope that you find the website helpful to you and please let us know if there is something we can do to make the website more useful.

 Healthcare Business Specialists is a Chattanooga, Tennessee-based consulting firm which specializes in rural health clinic reimbursement and prepares rural health clinic cost reports, annual evaluations, Quality Improvement plans, and RHC startups.  Mark R. Lynn (Curriculum Vitale) is trained as a certified public accountant and has over 25 years experience in the healthcare field with almost 15 years of experience devoted almost exclusively to rural health clinics.  We have been conducting rural health clinic seminars for over 12 years and each year over 80% of our attendees have been to one of our seminars in the past. Here are some links to help you navigate your way around our website.

 February 25, 2006:  The HBS Update Newsletter for March, 2006 can be found in the clicking here.  March, 2006

To register for HBS Update newsletters and RHC seminar information; enter your email address below:


RHC Update Seminars – Spring, 2006


January 27, 2006:  We hope that everyone is having a great new year and had a wonderful Holiday season.  It is back to work for us here at Healthcare Business Specialists as the cost report season is rapidly approaching.  This year will be the first for most of our clients to prepare the electronic file required by Medicare.  We use a program approved by CMS called HFS to prepare the cost reports and we have successfully prepared 10 or so cost reports since this requirement started with the 3/31/2005 cost reports.  In 2005, we prepared 100 RHC cost reports and look forward to working with you on this year's cost report.  We are mailing the purple cost report books to our clients in mid-February.  We did have to extensively revise the book this year due to the electronic filing requirement. If you are ready to start accumulating the information to prepare the cost report and do not want to wait on the notebooks; please follow the following link to our RHC cost report and RHC visit checklist.  (RHC Cost Report Checklist)(RHC Visit Checklist).

As always, we are having our RHC Update Seminars scheduled around the country and if we prepare your cost report your clinic is entitled to 2 free admissions to the seminars. 

The dates and places are correct on the following tables; however, we do not have the brochure updated as yet.  The fees and costs are exactly the same as the prior year.    The seminars will be start at 8:30 AM and will last to approximately 4:30.  Lunch and refreshments will be provided.  Additionally, a workbook and CD is included in the $425 registration charge and you can use the 2005 brochure to register or register online below.

Healthcare Business Specialists does not block hotel rooms for the seminar; so register early with the hotel.  Because, we do not block rooms and our contract is with the catering department of the hotel; the hotel may say that the function is not at that hotel (don't worry, it is).

 

Healthcare Business Specialists is registered with the National Association of State Boards of Accountancy (NASBA) as a sponsor of continuing professional education on the National Registry of CPE Sponsors.  Eight hours of credit is recommended for this course which is basic to intermediate level and no advanced preparation is required. (8 hours)

 

The following table lists the dates and locations of the RHC Update Seminars for Spring, 2006.  If you would like to sign up for the seminars from our website; please,  click on the hyperlink in the Location column of the table and complete the online registration form.

                        Location

Dates

Sponsor

Atlanta, Georgia

April 27, 2006

M & M Computers

Columbia, SC   

April 28, 2006

M & M Computers

Indianapolis, IN

May 4, 2006

MedMate by Versacom

St. Louis, Missouri 

May 5, 2006

M & M Computers

Dallas, Texas

May 12, 2006

M & M Computers

March 1, 2006:  We have added the 2006 RHC Update Seminar Brochure to the website.  The brochure can be found in 2 separate pages. If you can not get the download to work; email us and we will fax you a version.

2006 RHC Update Seminar Brochure in PDF Format.pdf

Page 1 of the 2006 RHC Update Seminar Brochure (1st Page)

Page 2 of the 2006 RHC Update Seminar Brochure (2nd Page)

 


 RHC Update CD is now available Online


Some of the information presented in our RHC Update seminars plus hundreds of files to help manage rural health clinics is now available at no charge on the internet.  The Indiana Rural Association has included this information on their website.  While the content is extensive, it is less than 10% of the information that you will receive on the CD. It is a great place to start if you are not familiar with rural health clinics. The CD contains presentations, templates, CMS pronouncements, policies and procedures, cost reporting workpapers, and newsletters related to RHCs.  A sample of the information can be accessed by clicking on any of the links in the following table.  The new CD can be obtained by coming to one of the RHC Update seminars or ordering the RHC Update Workbook. 

 
Tab 1 -  Administration Tab 7 - Billing Info HIPAA Security and Privacy
Tab 2 -  Outline of Presentation Tab 8 -  Local Medical Review P. Newsletters
Tab 3 -  Powerpoint Presentations Tab 9 -  Cost Report. Provider Enrollment/
Tab 4 -  Legislative Annual Evaluations Resources
Tab 5 -  Regulatory Certification & Policies Web Sites
Tab 6 -  Quality Assurance Government Reports 

 Listing of CMS Transmittal Letters and Other RHC Documents


Recent CMS Transmittals that Could Impact the Operation of RHCs

Transmittal No. 820 (Feb. 1, 2006): Revenue Codes for RHCs (http://www.cms.hhs.gov/Transmittals/Downloads/R820CP.pdf).
Transmittal No. 831 (Feb. 2, 2006): Medicare Secondary Payer (MSP) (http://www.cms.hhs.gov/Transmittals/Downloads/R831CP.pdf).
Transmittal No. 834 (Feb. 3, 2006): HPSA and PSA Bonus Billing  (http://www.cms.hhs.gov/Transmittals/Downloads/R834CP.pdf).
Transmittal No. 847 (Feb. 10, 2006): Hold on Medicare Payments (http://www.cms.hhs.gov/Transmittals/Downloads/R847CP.pdf).
Transmittal No. 850 (Feb. 10, 2006): Change Payment Floor Date for Paper Claims (http://www.cms.hhs.gov/Transmittals/Downloads/R850CP.pdf).
Transmittal No. 210 (Feb. 10, 2006): Second Participation Enrollment Period for 2006 (http://www.cms.hhs.gov/Transmittals/Downloads/R210OTN.pdf
Transmittal No. 207 (Feb. 1, 2006): New 2006 Rates for the Part B Fee Schedule (http://www.cms.hhs.gov/Transmittals/Downloads/R207OTN.pdf

 

Other Important RHC Documents

Subject

Hyperlink

2006 Poverty Guidelines released by CMS  (Click here to go to Poverty Guidelines)
2006 RHC Reimbursement Rate increase  (Click here to view transmittal with RHC rate increase)
2006 Skilled Nursing Home Medlearn Article   Skilled Nursing Home Medlearn Article from February, 2006
RHC Annual Evaluation Template from HBS  Annual Evaluation Template      Annual Evaluation Presentation
RHC Policy and Procedure Manual from HBS Policy and Procedure Checklist        P & P Template
RHC Billing Information Billing Cheat Sheet     RHC Billing Presentation   
RHC Cost Reporting Presentation from HBS Cost Reporting Presentation  Physician Compensation
Medicaid Regulations by State http://www.kff.org/mfs/index.jsp

HIPAA & NPI Teleconference & Video Conference on Rural Health


CMS Regions IV and VI  is sponsoring a teleconference on HIPAA and NPI at 1:00 – 2:00 PM, ET, Wednesday, February 22, 2006 entitled “NPI: Beyond the Tip of the Iceberg”.

This audio conference will deal specifically with NPI questions to ask as an organization’s subparts enumeration and crosswalks are accomplished and will be presented by

SPECIAL NOTE: Please call 877-203-0044 fifteen minutes prior to call start time and provide the conference ID number - 4199233

The PowerPoint Presentation for the teleconference is located at www.sharpworkgroup.com

NPI Fact Sheet: CMS has released a fact sheet on National Provider Identification numbers.  This two page document summarizes providers role in obtaining a NPI number.  To download; go to:

http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPIFactSheet_010906.pdf

A Video Conference entitled Rural Health Resources Live will be conducted March 1, 2006 from 1:00pm to 4:00pm and conducted by the Rural Assistance Center.  To view information related to the Video Conference follow the links below:

Home Page: http://ruralcenter.org/  Registration: Registration Information    Presentation: RHC Presentation


Helpful HRSA Links for RHCs


The following links are to the HRSA website. Many of the resources and services will help rural health clinics manage their practice.

 

Description

Links

RHC Technical Assistance HRSA ftp://ftp.hrsa.gov/TPR/TA-Practice-Management-Benchmarks-Word.doc
CMS Rural Health Center (several essential billing resources) http://www.cms.hhs.gov/center/rural.asp
HRSA Technical Assistance Web casts - Archives http://www.hrsa.gov/reimbursement/webcasts.htm
HRSA Training Online http://www.hrsa.gov/reimbursement/online-training.htm
HRSA Medicaid regulations by state http://www.hrsa.gov/reimbursement/TA-materials.htm
HRSA Archived Reports http://tasc.ruralhealth.hrsa.gov/archived.shtml
Benchmarks for physician practices ftp://ftp.hrsa.gov/TPR/TA-Practice-Management-Benchmarks-Word.doc
National Health Services Corp http://nhsc.bhpr.hrsa.gov/
National Health Service Corp Links to other organizations http://nhsc.bhpr.hrsa.gov/links/index.asp
NHSC Letter regarding automatic designation ftp://ftp.hrsa.gov/nhsc/legislation/RHC_Letter_Certification_form.pdf
National Health Service Corp community resources http://nhsc.bhpr.hrsa.gov/resources/community.asp
National Health Service Corp fact sheet on recruitment ftp://ftp.hrsa.gov/nhsc/factsheets/Information-for-Communities-and-Sites.pdf

 


 Medicare Advantage Plans and Rural Health Clinics


One of the most pressing problems facing Rural Health Clinics is contracting with and getting paid by Medicare Advantage plans.  David Wargo of CMS presented at the NARHC meeting in Washington, D.C. last year and his slides indicated if your RHC does not have a contract with the Medicare Advantage Plan; they must pay your Medicare cost per visit..  The following links will take you to the presentation and to 3 pages of Medicare Advantage regulations issued in December, 2005.

              CMS Presentation on Medicare Advantage Plans

                            Medicare Advantage Regulations issued December 22, 2005

Additionally, on February 8, 2006, The Office of Rural Health Policy (ORHP) through its Health Resources and Services Administration branch offered a Rural Health Clinics Technical Assistance Conference Call Series on Medicare Advantage and RHCs.  To view the presentation from this conference call please follow the hyperlink:

                            ftp://ftp.hrsa.gov/ruralhealth/MedicareAdvantageRHCs.pdf

According to David's presentation; regarding an RHC that treat's patients on a non-contract basis:

"If a rural provider prefers to treat MA enrollees on a non-contract basis, Federal law requires that all MA plans pay them not less than what you would have received for the same service under original Medicare payment rules.
 For RHCs that means cost-based reimbursement. --or rates equivalent to their costs.
MA regulations also require that MA plans, which pay providers on a non-contract basis, include in their payment any   Medicare “add-on” payments that are part of the FFS payment that you would have otherwise received from the Medicare FI or Carrier."
 

Here is what David's slides said regarding RHCs that contracts with Medicare Advantage plans.

Although Regional PPOs are permitted to pay contracting RHCs, CAHs and FQHCs on a cost basis (or at rates equal to costs), such terms of payment must be requested and negotiated by the provider.
MA plans are not mandated by Federal law to pay contracting RHCs, CAHs and FQHCs on a costs basis.
CMS is not obligated to provide supplemental payments to cover the difference, if any, between the MA payment to the RHC or CAH and the payment the clinic or hospital would be entitled to receive under their cost-based payment system."
 

This information was presented to David Wargo on February 17, 2006 and his response was as follows:

"This information is still correct.  Any time an MA enrollee seeks care from out-net-work provider,  that provider is entitled to receive payments equal to original Medicare.  The RPPO model allows its enrollees to op-out from their provider network, when this happens the MA plan must pay rates equal to original Medicare.  Please let to me know which plans and areas are problematic for your center.  I will do my best to get the my MA colleagues to intervene."

                                                                    David Wargo, CMS

                                                                    david.worgo@cms.hhs.gov

We recommend that the bill for any Medicare Advantage patient that is seen on a non-contract be prepared as a paper claim with an attachment on the RHC Interim Medicare Rate from the Part A Intermediary (it usually comes when the cost report is tentative settled). This indicates the rate that the claim should be paid.  Some plans are good about this and most are not.  It does slow down billing and is expensive to send out paper claims on an exception basis like this.

If you can communicate to the Medicare Advantage Plan that it is not going to hurt them financially to pay us our cost as that money is a Medicare "add-on" for them it makes it easier to loosen up the purse-strings as well. 

Medicare Advantage Plans either do not know the rules or ignore the RHC status when making payments to the majority of our clinics.  Many Medicare Advantage Plans abuse RHCs by using the deemed status clause in Medicare regulations.  To help understand this concept click on the following hyperlink to view an actual contract. (Deemed Status). The Medicare Advantage Plan industry will hold it's 4th Annual Meeting in January, 2007 and the RHC industry would be well served to have a representative at the meeting to educate the industry regarding rural health clinics.

 


 Medicare to stop all payments for 9 days in September


CMS has announced as mandated by Section 5203 of the Deficit Reduction Act of 2006; a brief hold will be placed on Medicare payments for all claims for the last nine days of the Federal fiscal year, i.e., September 22, 2006 - September 30, 2006. Claims held as a result of this one-time policy will be paid on October 2, 2006.  To view the Medlearn Matters article related to announcement follow the following link: 

                                                                         http://www.cms.hhs.gov/MedlearnMattersArticles/downloads/MM4349.pdf

Now, if we could only tell our suppliers and vendors that we are not going to pay them for 9 days in September as well.  If your practice is dependent on Medicare for making your payroll; you may want to call the bank and see about an increase in your line of credit to cover this shortfall.

 


 Updated Local Coverage Determination (LCD) for RHCs


On 12/28/2005 Riverbend converted the Local Medical Review Policies (LMRP) related to Rural Health Clinics into a Local Coverage Determination (LCD) and changed some of the language from the previous LMRP.  All rural health clinics that are serviced by Riverbend should review the document by going to the Riverbend website at  LCD-4874.  To view the FAQ go to: Riverbend LCD FAQ. This information should be presented to the providers of the clinics to ensure everyone has a good understanding of the expectations of the intermediary. (not that you are going to agree with all of them).  We will cover the new local coverage determinations in detail in our RHC Update seminar this year.

Many of our clients are interested in Skilled Nursing Home and NF visits.  The LCD specifically addresses this issue as follows:

"A physician/extender visit to a beneficiary in a skilled SNF bed or a swing bed is medically necessary on a monthly basis to evaluate the patient status as it relates to the skilled service. A physician/extender visit may constitute a medically necessary face-to-face more often than monthly only if the medical record supports the necessity of more frequent evaluation. (For the purposes of medical review, monthly shall mean no less than 21 days between visits.)

A physician/extender visit to a beneficiary in a non-skilled bed, intermediate care facility or nursing home is not medically necessary on a routine basis even if the nursing facility requires it as a condition of patient residence. However, Medicare does "presume" visits to be medically necessary if they are used to satisfy Federal Regulations. Based on these requirements, detailed in the Code of Federal Regulations [42 CFR 483.40], a visit to a patient in a non-skilled bed, ICF or nursing home will be considered medically necessary if it has been approximately 60 days (for the purposes of medical review at least six weeks) since the last visit. At frequencies greater than this the encounter is only medically necessary if it occurs in response to a patient complaint or in follow-up to an established medical condition; in both instances the visit is medically necessary only if an office visit would be medically necessary under the same circumstances."

 


 CMS Distribution & Mailing Lists


CMS offers an electronic mailing list service for those interested in receiving news from the Centers for Medicare & Medicaid Services (CMS). If you follow the link below you can subscribe or unsubscribe from any of CMS's mailing lists. Please note that the National Institutes of Health (NIH) hosts all CMS listservs.  http://www.cms.hhs.gov/apps/mailinglists/

 


HBS Update - February, 2006


February 11, 2006:  Every year I worry that there will not be anything to update our clients and seminar attendees on regarding the operation and reimbursement of RHCs; however, our government never fails me and usually produces a rash of changes this time of year.  They did not fail me this year.  Here are a couple of things that we will be discussing in our seminars:

RHC Revenue Codes for billing purposes will be expanded dramatically on July 1, 2006. (Of course when you start with only 2 codes to begin with it is not hard to expand dramatically).  On February 1, 2006, CMS announced that revenue codes used for billing purposes in rural health clinics would be expanded effective July 1, 2006.  The new codes are as follows:

This information can be found in a Medlearn Matters article and a CMS Transmittal at the following website addresses: 

Medlearn:        http://new.cms.hhs.gov/MedlearnMattersArticles/downloads/MM4210.pdf

Transmittal      http://www.cms.hhs.gov/Transmittals/downloads/R820CP.pdf

 


Deficit Reduction Act of 2005 signed cutting $11 billion from Medicare and Medicaid and 2007 Budget proposes an additional $37 billion in cuts.

President Bush signed the Deficit Reduction Act (DRA) of 2005, See Washington Post Article which will reduce Medicaid spending by almost $5 billion and Medicare spending by $6 billion over the next five years. Additionally, the president's FY07 budget proposal was released, which includes a $36 billion cut in Medicare spending and a $1 billion cut in Medicaid spending over five years. The 2007 budget President Bush presented to Congress on Monday included $36 billion in Medicare cuts over five years, with $20 billion of those cuts resulting from lower reimbursement to hospitals.

DRA does contain some good news for physicians as the Medicare Part B payments will not be reduced by 4.4% as required under prior law. Payments will be frozen at the 2005 level and claims that already been paid with the 4.4% reduction factor will not have to be resubmitted.  The Medicare Carriers have been instructed to make an adjustment to the claims and send that payment to the providers and open the enrollment period for physicians for 45 days.

To download the Deficit Reduction Act of 2005 go to the following hyperlink:

http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=109_cong_bills&docid=f:s1932enr.txt.pdf

To view the press release regarding the 2007 budget go the following hyperlink:

http://www.whitehouse.gov/news/releases/2006/02/20060206-2.html

The only specific mention of rural health clinics in the Deficit Reduction Act of 2005 relates to Medcaid managed care if I am reading the bill correctly.  I am not sure what this means; but, I am sure I will know by the time I get back from the National Rural Health Association meeting in Washington, D.C. in early March.  Here's the quote:


‘‘(4) COVERAGE OF RURAL HEALTH CLINIC AND FQHC SERVICES.—

Notwithstanding the previous provisions of this section,a State may not provide for medical assistance through enrollment of an individual with benchmark coverage or benchmark equivalent coverage under this section unless—‘‘(A) the individual has access, through such coverage or otherwise, to services described in subparagraphs (B) and (C) of section 1905(a)(2); and ‘‘(B) payment for such services is made in accordance with the requirements of section 1902(bb).’’. (b) EFFECTIVE DATE.—The amendment made by subsection (a)takes effect on March 31, 2006.


NPI Fact Sheet: CMS has released a fact sheet on National Provider Identification numbers.  This two page document summarizes providers role in obtaining a NPI number.  To download; go to:

http://www.cms.hhs.gov/NationalProvIdentStand/Downloads/NPIFactSheet_010906.pdf


Medicare Deductible for 2006 increases to $124.00 impacts Negative Adjustments


Rural Health Clinics and other Part B providers are coming to grips with the formula change for the Medicare Part B deductible that was implemented a couple of years ago.  The Medicare Deductible increases annually based upon the growth in the Medicare Premium for Part B (or some number like that - what's important is it going up between 10% and 14% per year).  The immediate impact is that Medicare is taking a lot more money away from RHC through Negative adjustments.  Yes, they take money away from you for seeing Medicare patients.  Here is how it works:  A Medicare Patient is treated and has a RHC charge of (99214 or 99215 for example) $124.00 for the visit.  The patient would owe the RHC, $124.00 for the deductible.  Hopefully, you would collect that amount at the time of service or bill a secondary insurance coverage (AARP for example).  When you submit the claim to Medicare; Medicare actually takes $41 out of your next check and reduces your payment.  Medicare makes the following calculation regarding your payment:

Table One - Assumptions

DescriptionAmountComments
RHC charge (Part A only)$124Actual patient charge for the service
Interim Payment Rate from Medicare$72.76This is maximum rate for 2006
Medicare payment percentage.80Medicare only pays 80% of the rate
Coinsurance payment percentage.20This should be collected from the patient

 

Table Two - Calculations

DescriptionAmountDescriptionAmount
RHC charge (Part A only)$124.00Interim Payment Rate from Medicare$72.76
Coinsurance payment percentage.20Medicare payment percentage.80
Patient Coinsurance 24.80Medicare Payment58.20
       
    Total Patient & Medicare83.00
    Paid by Patient (Charge)$124.00
    Negative Reimbursement $41.00

 

These tables illustrate the logic that intermediaries adopt when recouping money from RHCs through negative reimbursement.  Some intermediaries have different formulas for recouping; however, the basic concept is basically the same.

It is pretty easy to see that not only rural health clinics but all Part B providers are going to have adjust our collection efforts to focus on the individuals and not Medicare. In a few short years, the Medicare deductible will be in excess of $250 and Medicare will represent about 20% of the clinic's collection from the patient.  Right now the average percentage is 60% from Medicare and 40% from the patient. (A simple way to find out your percentage is look at your P S and R report from Medicare that is used to prepare your cost report).

There is not much a clinic can do to combat this trend; however, some clinics and Part B physicians have for years not billed any Medicare during January and February; so as not to be the clinic that gets stuck with deductible.  The assumption is another physician such a specialists will bill the service first and be the one who gets stuck with the deductible. Sort of a strange game of musical chairs.  Please don't send any 10 page dissertations on the ethics, or implications on cash flow, or office flow of work, etc., etc. of doing something like that.  I am just saying that some providers do this and they think it works for them; and, I am not advocating a particular strategy.

 

 

Riverbend to Conduct RHC Workshop on March 10, 2006

 

A Medicare Specific Rural Health Clinic Workshop will be conducted by Riverbend GBA (RGBA) staff. This workshop is specifically designed for Rural Health Clinic (RHC) providers to enhance and supplement your basic Medicare training. The RGBA staff will provide information to the RHCs in the following areas: RGBA & CMS website, CMS internet manuals, RGBA reports, claims processing, MSP, reimbursement, cost reporting and medical review.

To Register for the Riverbend RHC Workshop Click Here

 


  Riverbend is no longer providing free Cost Report Software

Riverbend GBA has in the past providing free RHC cost reporting software that could be downloaded from their website.  However, with the change this year to the electronic filing of RHC cost reports, Riverbend has stopped providing this free service.  A link to a listing of approved cost report software vendors (this list is just for software not cost report preparation) and their contact information is provided below:

 

 

 


Office of Inspector General report on RHCs Released


 

August, 2005:  The Office of Inspector General has released a report discussing the location status of Rural Health Clinics (RHCs). This report includes statistics on the number of RHCs in locations that do not have current shortage designations and RHCs in areas no longer considered rural. It also includes historical overview of the RHC location requirements and recommendations for improvement.  To download the report go to the following hyperlink:

Status of the Rural Health Clinic Program


                                            

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