NARHC Spring Institute...They must be bundled with the RHC encounter. They are not separately...

NARHC Spring InstituteWednesday, March 20, 2019

San Antonio Conference

Welcome & App Tutorial

Wm. John Gill, PA-CPresident

NARHC

NARHC MOBILE APPWHAT YOU NEED ABSOLUTELY NEED TO KNOWwww.tripbuildermedia.com/apps/narhc

WWW.TRIPBUILDERMEDIA.COM/APPS/NARHC

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MYSCHEDULE

Why to Create a MySchedule and HowWhy take the time to fill out your schedule?By entering your schedule in MySchedule we are able to track your CEU credits.

Space is limited in some lectures; by selecting the sessions we are better able to determine if and when the session is full.

It helps us determine what areas of information you find useful, determining what may be presented at future meetings.

How do I create a MySchedule?Enter each session you plan to attend into this section by clicking on the radial button to the left of the session under Schedule. It’s that simple!

SESSION SURVEYS

How to Complete a Session Survey

Why take the time to fill out the surveys?

By completing the session surveys you not only provide invaluable feedback to help us improve and better serve you, but you also earn necessary points to qualify for the prize drawings. The Grand Prize is an Amazon Echo Plus with a smart light.

How do I complete a Session Survey?Select the session you have just attended by either selecting the Schedule module or through MySchedule and click on the thumbs up survey button. Please complete each question to earn your points (comments are not necessary). Once finished hit the submit button at the bottom of the page. You can also go back to sessions you attended if you didn’t have time before to complete the survey.

ATTENDEE GAMEHow to Participate in the Attendee GameWhy do the attendee game?Prizes!!! By obtaining the minimum points required you will be automatically entered into the prize drawings held Thursday morning at 8:25 and you must be present to win. The Grand Prize is an Amazon Echo Plus with a smart light.

How do I obtain the minimum points to be entered in the Prize Drawing?Visit each exhibitor’s table to receive the correct answer to their unique. Complete the Session Surveys for each session you've attended. By following these steps you will obtain the minimum required points to be entered into the prize drawings. For your convenience we have stylus pens available at the NARHC Desk.

*Be certain you've selected the correct answer before hitting the submit button. Answers cannot be changed once submitted and you will not meet the minimum required for the prize drawings.

FLOOR PLANS

Coming Soon…A NEW

Educational Opportunityfrom NARHC

https://drive.google.com/file/d/13nmz9rvDGPK23ChsdFILCzEsXb0yNLwO/view

Coming Soon…

A NEWEducational Opportunity

from NARHC

RHC Beginning Billing 101Charles James, Jr.

MBAPresident & CEO

North American HealthcareManagement Services

What is an RHC?

Rural Health Clinics were established by the Rural Health Clinic Service Act of 1977 to address an inadequate supply of physicians serving Medicare beneficiaries in underserved rural areas, and to increase the utilization of nurse practitioners (NP) and physician assistants (PA) in these areas. RHCs have been eligible to participate in the Medicare program since March 1, 1978, and are paid an all-inclusive rate per visit for qualified primary and preventive health services.

(Medicare Benefit Policy Manual. Chapter 13. Section 10.1.)

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What is an RHC?

A Rural Health Clinic (RHC) is a clinic certified to receive special Medicare and Medicaid reimbursement.

51% of Clinic Services must be Primary Care (FP,IM,OB,Ped) The purpose of the RHC program is improving access to primary care in

underserved rural areas. The clinic must be staffed at least 50% of the time with a midlevel

practitioner.(Rural Assistance Center FAQ)

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The Rules - 42 CFR 491

This is the Code of Federal Regulations (CFR) which stipulates Rural Health Clinics’ Conditions for Certification.

http://www.cms.gov/Regulations-and-Guidance/Legislation/CFCsAndCoPs/RHC_FQHC.html

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Rural Health Clinic Requirements

Compliance with Federal, State, and Local laws Location of Clinic Physical Plant and Environment Organizational Structure Staffing and Staff Responsibilities Provision of Services Policy and Procedure Manual Medical Records Emergency Preparation Annual Evaluation (vs. Quality Assurance)

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RHC Regulations and Interpretive Guidelines

Social Security Act Section 1861(aa)(2)(K)42 CFR §405.2402 (Basic Requirements)42 CFR Part 491, Subpart A (Conditions for Participation!)State Operations Manual – Appendix G (Surveyor Guidance)Accreditation Organization Standards: AAAASF The Compliance Team

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The RHC Encounter Rate

The Current RHC maximum encounter rate CY 2019 is $84.70. (for independent/freestanding RHCs or PBRHCs ineligible for an uncapped rate).

“In general, the all-inclusive rate (AIR) for an RHC or FQHC is calculated by the MAC/FI by dividing total allowable costs by the total number of visits for all patients. Productivity, payment limits, and other factors are also considered in the calculation.”

(Medicare Benefit Policy Manual. Chapter 13. Section 70.)

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RHC Productivity Standard

1 FTE Physician – 4,200 Visits1 FTE NP or PA – 2,100 Visits

If the RHC or FQHC has furnished fewer than expected visits based on the productivity standards, the MAC/FI substitutes the expected number of visits for the denominator and use that instead of the actual number of visits.

(Medicare Benefit Policy Manual. Chapter 13. Section 70.4.)

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RHC Rate and Cost Reporting

The RHC Encounter Rate is set via the RHC Cost Report. Provider-based Clinics file as part of the hospital cost report. Costs must appropriately allocated and tracked for the RHC space and

personnel. Provider FTEs should be measured via formal time study. Only time spent in the RHC counts. Medical Director, Physician, PA, NP, Nursing FTEs have a major impact on

cost reporting. Laboratory Expenses must be allocated and reclassified appropriately.

(RHC vs. Non-RHC)

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Independent RHCs

Independent RHCs are generally private physician offices or hospital clinics whose parent is > 50 beds.

RHC encounters are paid using the current RHC cap. Independent RHCs must file an annual cost report, which is due 5

months after the end of each fiscal year. Failure to file timely cost reports can result in full refunds of RHC

payments.

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Provider-Based RHCs

Provider-based RHCs (PBRHC) are those owned by a parent entity such as a hospital, nursing facility, or home health agency. PBRHCs owned by a hospital with 50 beds or less qualify for an un-

capped RHC rate. PBRHCs whose parent entity is greater than 50 beds have the same cap

as independents. PBRHCs rate is set under the parent entity’s cost report. Claims are billed to the MAC which services the parent entity.

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Provider-Based RHCs: Not Outpatient Departments

42 eCFR 413.65 (a)(2):For purposes of this part, the term “department of a provider” does not include an RHC or, except as specified in paragraph (n) of this section, an FQHC.

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Outpatient PPS 2017

“A key proposal in this year’s rule is to implement Section 603 of the Bipartisan Budget Act of 2015, which will affect how Medicare pays for certain items and services furnished by certain off-campus outpatient departments of a provider (hereinafter referenced as off-campus “provider-based departments” (PBDs).”https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-06.html

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RHC Claims - Medicare Part A

The Centers for Medicare and Medicaid Services administers Rural Health Clinics payments under Medicare Part A. RHC services are a Part B (Physician Service) benefit, but our reimbursement structure is Medicare Part A.

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Medicare Part B (FFS)

In the RHC world, the term ‘Medicare Part B’ typically indicates thoseclaims which will continue to be paid ‘fee-for-service’ and billed on a CMS-1500 under the Medicare Physician Fee Schedule (MPFS) paymentstructure.

RHC claims are NOT paid based on the Medicare Fee Schedule. Non-RHC services are those that may be paid outside of the RHC Benefit.

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Rural Health Clinics and MIPS

Medicare Part A reimbursement for claims submitted on a CMS-UB04 is NOT subject to MIPS negative/positive payment adjustments at present.

Any non-RHC/non-FQHC billing which is submitted on a CMS-1500 WILL be subject to MIPS adjustments.

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Qualified RHC Providers

An RHC encounter can be billed for the following providers: Physicians (MD, or DO) Nurse Practitioners Physician Assistants Certified Nurse Midwives Chiropractor, Dentist, Optometrist, Podiatrist

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Behavioral Health Providers

Medicare RHC providers are: Clinical Psychologist (PhD) LCSW LCPC or CPC is not payable by Medicare(Check with your own state to see if LCPC or CPC are eligible – in most states they are not)

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Rural Health Services

Physicians' services, as described in section 100; Services and supplies incident to a physician’s services, as described in section

110; Services of NPs, PAs, and CNMs, as described in section 120; Services and supplies incident to the services of NPs, PAs, and CNMs, as

described in section 130; Clinical Psychologist and Clinical Social Worker services, as described in

Section 140; Services and supplies incident to the services of CPs and CSWs, as described

in Section 150; and Visiting nurse services to the homebound as described in Section 180.

(Medicare Benefit Policy Manual Chapter 13)

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Incident-to Services Defined

Incident-to services are considered covered and paid under the RHC. They must be bundled with the RHC encounter. They are not

separately billable or payable. Services that do not occur on the same date as the encounter can be

bundled if they occur 30 days before or after. The effect on payment is an increase in the charge, and therefore in the

co-insurance. The cost for these services are included in the cost report, but are not

separately payable on claims.

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RHC Locations

RHC visits may take place in: the RHC or FQHC, the patient’s residence (including an assisted living facility), a Medicare-covered Part A SNF (see Pub. 100-04, Medicare Claims

Processing Manual, chapter 6, section 20.1.1), or the scene of an accident.

(Medicare Benefit Policy Manual. Chapter 13. Section 40.1)

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Never a RHC Location

RHC Visits may never take place in: an inpatient or outpatient department of a hospital, including a CAH, or a facility which has specific requirements that preclude RHC or FQHC

visits (e.g., Medicare comprehensive outpatient rehabilitation facility, a hospice facility, etc.)

(Medicare Benefit Policy Manual. Chapter 13. Section 40.1)

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The RHC Encounter is:

“An RHC or FQHC visit is a medically-necessary medical or mental healthvisit, or a qualified preventive health visit. The visit must be a face-to-face(one-on-one) encounter between the patient and a physician, NP, PA,CNM, CP, or a CSW during which time one or more RHC or FQHC servicesare rendered.”


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Qualifying Visits

Medical Services RHCs shall report one service line per encounter/visitwith revenue code 052X and a qualifying medical visit from the RHCQualifying Visit List. Payment and applicable coinsurance and/ordeductible shall be based upon the qualifying medical visit line.

RHC Qualifying Visit Listhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/RHC-Qualifying-Visit-List.pdf

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RHC Services – Claim Form

RHC Services are submitted on a CMS-UB04 claim form. The electronic format is ANSI837-Institutional. Type of Bill is “711” for an original claim. All services must be reported using the appropriate revenue code. All claims must have a qualifying visit denoted with a “CG” Modifier. Incident-to services must be reported on the claim, but bundled with

the qualifying visit.

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Revenue Codes

0521 All Clinic Visits and Professional Services by qualified RHC provider;0522 Home visit by RHC provider;0524 Visit by RHC provider to a Part A SNF bed;0525 Visit by RHC provider to a non-SNF bed,

NF or other residential facility (non-Part A);0527 Visiting Nurse service in home health shortage area0528 Visit by RHC provider to other non-RHC site (scene of an accident) 0250 Pharmacy (Does not need the HCPCS)0300 Venipuncture0636 Injection/Immunization0780 Telehealth0900 Behavioral Health

CG Modifier

“…beginning on October 1, 2016, RHCs shall add modifier CG (policycriteria applied) to the line with all the charges subject to coinsurance anddeductible.” (Med Learn Matters SE1611)

“If only preventive services are furnished during the visit, the RHC shouldreport modifier CG with the preventive HCPCS code that represents theprimary reason for the medically necessary face-to-face visit and thebundled charges.”

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Billing Example: CG Modifier and Line Items

FL42 FL43 FL44 FL45 FL46 FL47Rev CD Desc HCPCS/CPT DOS Units Total Charge

0521 Office Visit Est III 99213CG 4/2/2019 1 100.00$ 0001 Total Charge 100.00$

An established patient is seen and a qualifying visit of 99213 for $100 is generated. The applicable coinsurance and/or deductible shall be based upon $100.

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Billing Example: Medical Visit plus Ancillary

The charge amount for Toradol ($30.00) and the administration($20.00) will be added to the 99213 ($100) for a qualifying visitline of $150.00. The total charge line is artificially inflated – butcorrect.


0521 OV Est 3 99213 CG 4/2/2019 1 150.00$ 0636 Injection Admin 96372 4/2/2019 1 20.00$ 0636 Toradol J1885 4/2/2019 1 30.00$ 0001 Total Charge 200.00$

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Service Detail

Service detail lines can be reported as $.01 or greater. The additional services lines CAN be reported as $.01. This eliminates artificial inflation of revenue, adjustments, and AR.

The Toradol charge amount ($30.00) plus $.01, the injection administration (20.00)plus $.01 are bundled with the $100 charge on the 99213 qualifying visit line.Medicare will use the line with the qualifying visit code (99213) to determine thetotal charge and calculate co-insurance.


0521 OV Est 3 99213 CG 4/2/2019 1 150.00$ 0636 Injection Admin 96372 4/2/2019 1 0.01$ 0636 Toradol J1885 4/2/2019 1 0.01$ 0001 Total Charge 150.02$

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RHC Use of Modifiers -59 and -25

Modifier-59 indicates that separate conditions on the same treated are unrelated. This is used only a subsequent illness or injury on the same day as another visit. Modifier-25 in an RHC in interchangeable with -59!

Modifier-59 and -25 indicate two encounters. -25 is different in an RHC. Modifier 25 or 59 is only on the SECOND line item UB-04 on a claim form.

RHC Pro Tip: Modifier-25 is NOT used to distinguish an Evaluation and Management Service from a procedure.

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Billing Example: Medical Visit plus Procedure

Medicare will use the line with the qualifying visit code (99213) to determine the total charge and calculate co-insurance.


0521 OV Est 3 99213 CG 4/2/2019 1 250.01$ 0521 Procedure 11100 4/2/2019 1 0.01$ 0001 Total Charge 250.02$

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Preventive RHC Services

RHC services also include certain preventive services. These include: Welcome To Medicare Visit (G0402) Annual Wellness Visit/Subsequent Annual Wellness (G0438/G0439) Medicare-covered Preventive Services (DMST is NOT eligible as an RHC Visit!) Influenza, Pneumococcal (Medicare Cost Report – Medicare Flu/Pneumo Only) Chronic Care Management (G0511/G0512) Virtual Communication Services (G0071)

(Medicare Benefit Policy Manual Chapter 13)

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Preventive Services and Same Day Billing

“RHC/FQHC can receive a separate payment for an encounter in additionto the payment for the [Certain Preventive Services] when they areperformed on the same day.” MLN SE1039

The IPPE (G0402) is the only Medicare Preventive Service eligible for same-day billing.

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Preventive Services and Stand-Alone Encounters

All other preventive services are ‘stand-alone’ encounters. If a “StandAlone” encounter is the only service rendered on a particular date ofservice, then it will be paid at the AIR. If it is furnished on the same day asanother medical visit, it is not a separately billable visit.

The beneficiary coinsurance and deductible may be waived, depending onthe service rendered.

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Medicare Preventive Services (MPS)

“RHCs and FQHCs are paid for the professional component of allowablepreventive services when all of the program requirements are met andfrequency limits (where applicable) have not been exceeded.

The beneficiary copayment and deductible (where applicable) is waivedby the Affordable Care Act for the IPPE and AWV, and for Medicare-covered preventive services recommended by the USPSTF with a grade orA or B.”

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Non-Rural Health Services

“RHCs and FQHCs must be primarily engaged in furnishing primary careservices, but may also furnish certain services that are beyond thescope of the RHC or FQHC benefit.

If these services are authorized…the services must be billed separately(not by the RHC or FQHC) to the appropriate A/B MAC under thepayment rules that apply to the service.

RHCs and FQHCs must identify and remove from allowable costs on theMedicare cost report all costs associated with the provision of non-RHC/FQHC services such as space, equipment, supplies, facilityoverhead, and personnel.”

(Medicare Benefit Policy Manual Chapter 13; Section 60)48

Non-Rural Health Services

Certain services are not considered RHC or FQHC services either because they 1) arenot included in the RHC or FQHC benefit, or 2) are not a Medicare benefit. Non-RHC/FQHC services include, but are not limited to:

Medicare excluded services Ambulance servicesTechnical component of an RHC or FQHC service

Prosthetic devices

Laboratory services Body BracesDurable medical equipment Practitioner services at certain other

Medicare facilityTelehealth distant-site services Hospice ServicesGroup Services

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Diagnostic Testing and Lab: Independent

The professional component for X-Ray, EKG, and other diagnostic testing is bundled with the RHC encounter. The technical component of these tests are billed to the Medicare Part

B carrier using the fee-for-service provider number. All lab services are also billed to the Part B carrier.

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Diagnostic Testing and Lab: Provider-Based

The professional component for X-Ray, EKG, and other diagnostic testing is bundled with the RHC encounter. The technical components for X-Ray, EKG, ultrasounds, etc. are billed to

the FI using the hospital CCN number. Lab services are also billed to the FI using the hospital CCN number.

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Medicare Fees (Patient Charges)

“RHCs and FQHCs must charge Medicare beneficiaries the same rate that non-Medicare beneficiaries are charged.”


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Medicare Payments

“In general, Medicare pays 80 percent of the RHC or FQHC’s all-inclusive rate, subject to a per-visit payment limit. The beneficiary in an RHC must pay the deductible and coinsurance amount.”


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Visiting Specialists in an RHC

Any qualified provider (MD, DO, NP, PA) can see patients in an RHC. RHC must provide primary care services fifty-one percent of operating

hours. (FP, IM, Peds, OB)

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Medicare Advantage Plans

Medicare Advantage plans are considered commercial payers for RHC purposes and cost reporting purposes. Most of these will pay your RHC encounter rate and follow

Medicare RHC reimbursement. RHC services should be submitted on a CMS-UB04; Non-RHC services may be submitted on a CMS-1500. Pneumoccal and Influenza injections should not be reported

on the RHC Cost Report.

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Telehealth

Report on UB04 with Q3014. (app. $23.17) Can accompany an E/M service or be reported alone. ‘Remote’ physician bills an E/M code with modifier.

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Telehealth

RHCs and FQHCs are not authorized to serve as a distant site fortelehealth consultations, which is the location of the practitioner at thetime the telehealth service is furnished, and may not bill or include thecost of a visit on the cost report.* (*State rules vary!!)

This includes telehealth services that are furnished by a RHC or FQHCpractitioner who is employed by or under contract with the RHC orFQHC, or a non-RHC or FQHC practitioner furnishing services through adirect or indirect contract.

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Chronic Care Management becomes Care Coordination

CCM services furnished on or after January 1, 2018: CCM services can be billed byadding the general care management G code, G0511, to an RHC or FQHC claim, eitheralone or with other payable services. Payment is set annually at the average of thenational non-facility PFS payment rate for CPT codes 99490 (20 minutes or more ofCCM services), 99487 (60 minutes or more of complex CCM services), and 99484 (20minutes or more of general behavioral health integration services).

For CCM services furnished between January 1, 2016 and December 31, 2017: CPT code 99490 ONLY applies to these old claims. 99490 is dead.

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G0511: General Care Management Services

G0511: General Care Management Services billed alone or with other payable services on a RHC or FQHC claim. This code could only be billed once per month per beneficiary, and could not be

billed if other care management services are billed for the same time period. Payment for G0511 is set at the average of the 3 national non-facility PFS payment

rates for the CCM (CPT code 99490 and CPT code 99487) and general BHI (CPT code99484).

The current payment rate is $61.37 for FY2018. The rate is updated annually based on the PFS amounts and coinsurance applies.

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Effective January 1, 2019: Virtual Communication

RHCs can receive payment for Virtual Communication Services when at least5 minutes of communication technology-based or remote evaluation servicesare furnished by an RHC practitioner to a patient who has had an RHC billablevisit within the previous year.

The medical discussion or remote evaluation is for a condition not related to an RHC service provided within the previous 7 days, and -

The medical discussion or remote evaluation does not lead to an RHC visit within the next 24 hours or at the soonest available appointment.

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Virtual Communication Services - Payment

G0071 (Virtual Communication Services) is billed either alone or with other payable services.

Payment for G0071 is set at the PFS national average of the non-facility payment rate for HCPCS code G2012 (communication technology-based services) and HCPCS code G2010 (remote evaluation services).

For 2019, the payment amount for code G0071 will be $13.69 (average of HCPCS codes G2012 and G2010).

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G2010: Virtual Communication Services

Virtual Check-In: Brief Communication Technology-based Service: by a physician or other qualified health care professional; provided to an established patient; not originating from a related E/M service provided within the

previous 7 days; nor leading to an E/M service or procedure within the next 24

hours or soonest available appointment; 5-10 minutes of medical discussion.

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G2012: Virtual Communication Services

Remote evaluation of recorded video and/or images submitted by an established patient (e.g., store and forward), including interpretation with follow-up with the patient within 24

business hours, not originating from a related E/M service provided within the previous

7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.

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RHC - CMS Resources

Virtual Communication FAQhttps://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/VCS-

FAQs.pdf

State Operations Manual Appendix G (Updated 1.2.18)https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_g_rhc.pdf

Provider-Based Rules (42 CFR 413.65)https://www.law.cornell.edu/cfr/text/42/413.65

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RHC - CMS Resources

Medicare Claims Processing Manual – Chapter 9 RHC/FQHC Coverage Issues www.cms.gov/manuals/downloads/clm104c09.pdf

Medicare Benefit Policy Manual – Chapter 13 RHC/FQHC www.cms.gov/Regulations-and Guidance/Guidance/Manuals/Downloads/bp102c13.pdf

Medicare Claims Processing Manual UB04 Completionwww.cms.gov/manuals/downloads/clm104c25.pdf

Medicare Benefit Policy Manual- Chapter 15 Other Serviceswww.cms.gov/Regulations-and Guidance/Guidance/Manuals/Downloads/bp102c15.pdf

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Contact Information

Charles A. James, Jr.North American Healthcare Management ServicesPresident and CEO888.968.0076cjamesjr@northamericanhms.comwww.northamericanhms.com

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RHC Medicare Cost Reporting 101

Katie Jo RaebelCPA, PartnerWipfli, LLP

Rural Health Clinic Medicare Cost Report Overview

Allowable Costs

Non-RHC Costs

Provider Staffing

RHC Visits/Provider Productivity

Medicare Flu and Pneumonia Reimbursement

Medicare Bad Debt

Operational Strategies

Today’s Agenda

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Rural Health ClinicMedicare Cost Report Overview

The Medicare cost report is the method of reconciling payments made by Medicare with the allowable costs for providing services.

• If total payments received from Medicare exceed the allowable costs, the provider must pay the difference to Medicare.

• If total Medicare payments are less than the allowable costs, Medicare will make an additional payment to the provider.

Note: Medicaid cost report filing requirements vary by state.

Medicare Cost Report

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There are two types of RHCs; cost reporting is slightly different for each:

• Independent RHCs submit an RHC cost report to one of five regional fiscal intermediaries (transitioning to MAC).

• Provider-based RHCs submit an RHC cost report as a subset of the host provider (usually a hospital).

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• The cost report is due five months after the close of the period covered.

• It must be filed electronically.

• Terminating cost reports are due 150 days after the termination of the provider agreement.

• An extension to file the cost report may be granted by the intermediary only for extraordinary circumstances such as a natural disaster, fire, or flood.

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• What if you don’t file the cost report within the 150 days?

- Currently, there is no penalty imposed for late filing; however, Medicare will stop payments to the RHC.

- Medicare will ask for the money paid in interim payments to be paid back.

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What Is Needed to Prepare the Cost Report?

1. Financial statements2. Cost report software3. Provider/practitioner FTE data4. Visits by practitioner5. Wage and benefit summary, by position6. Equipment (fixed asset) records7. PS&R Report (Medicare charges and payments) 8. Influenza/pneumococcal vaccines (injection totals and invoices)

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What Is Needed to Prepare the Cost Report?

9. Laboratory costs10. Radiology/other diagnostic costs11. Advertising costs12. Other items:

- Medicare bad debt log- Additional costs not included in financial statements- Costs included in financial statements not related to

RHC services

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Cost Report Components• Trial Balance of Expenses• Reclassification and Adjustment of Trial Balance of Expenses˗ Reclassifications˗ Adjustments˗ Related-party adjustments

• RHC Provider Statistics• Flu/PPV Vaccine Costs• Visits (part I), Overhead (part II)• Determination of Medicare Reimbursement (part I) and

Payment (part II)

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Allowable Costs

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Allowable Costs

Allowable RHC Costs:

• Defined at 42 CFR 413.

• Explained in Provider Reimbursement Manual, Pub. 15.

“Allowable costs must be reasonable and necessary and may include practitioner compensation, overhead, equipment, space, supplies,

personnel, and other costs incident to the delivery of RHC services.” − RHC Medicare Benefit Policy Manual

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Allowable Costs

What is the source document for the “allowable RHC costs”?

• For provider-based RHCs˗ Departmental summary reports˗ Internally prepared financial statements˗ Hospital cost report data

• For independent RHCs˗ Financial statements prepared by outside accountants˗ Internally prepared financial statements˗ Tax returns?

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Non-RHC Costs

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Non-RHC Costs

Identify Costs of Common Non-RHC Services• Chronic Care Management• DME• Hospital services (inpatient/ER/ASC)• Laboratory services• Medical directorships• Mammography• Telehealth• Radiology services

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Non-RHC Costs

Example - Laboratory Services

Most common direct costs associated with lab:• Lab tech salaries/benefits• Nursing salaries/benefits• Reagent costs• Other lab supplies• Lab equipment depreciation• CLIA licensure/reference lab fees

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Provider Staffing

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Provider Staffing

Cost report requires separation of provider time (and cost)

• Health Care Provider FTEs:˗ Physician˗ Physician Assistant˗ Nurse Practitioner˗ Visiting Nurse˗ Clinical Psychologist˗ Clinical Social Worker

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Provider Staffing

• Record provider FTE for clinic time only (this includes charting time):˗ Time spent in the clinic˗ Time with SNF patients˗ Time with swing bed patients

• Do not include non-clinic time in provider productivity:˗ Hospital time (inpatient or outpatient)˗ Administrative time˗ Committee time

• Provider time for visits by physicians under agreement who do not furnish services to patients on a regular ongoing basis in the RHC are not subject to productivity standards.

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Provider Staffing

Sample Reconciliation of Provider FTE:

Clinical FTE Administrative FTEHospital FTEMedical Director FTETotal FTE

0.700.050.200.051.00

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RHC Visits/ Provider Productivity

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RHC Visits

“A RHC visit is defined as a medically-necessary medical or mental health visit, or a qualified preventive health visit. The visit must be a

face-to-face (one-on-one) encounter between the patient and a physician, NP, PA, CNM, CP, or a CSW during which time one or more RHC services are rendered. A Transitional Care Management (TCM)

service can also be a RHC or FQHC visit. A RHC visit can also be a visit between a home-bound patient and an RN or LPN under certain

conditions.” − RHC Medicare Benefit Policy Manual

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RHC Visits

• Total visits, the denominator in the cost per visit calculation, should include all “visits” that take place in the RHC during hours of operation, home visits, and SNF visits for all payers.

• Total visits should not include hospital visits (either inpatient or outpatient visits) or “nurse-only” visits in the RHC setting.

NOTE: The cost-per-visit calculation considers total costs;therefore, all visits (regardless of payer type)should be included in the cost report.

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Payment Rate Calculation

This is a review (and there may be a test) . . . Allowable RHC Costs

Rural Health Clinic Visits=

RHC Cost Per Visit (Rate)

(Not to exceed the maximum reimbursement limits.)

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RHC Visits

• Counting of “visits” is easier said than done.

• Computer-generated reports may be misleading:

˗ Counting units of service instead of visits˗ Including non-visits (e.g., nurse-only 99211)˗ Including non-RHC visits (e.g., hospital visits)˗ Excluding non-billable visits (e.g., cash only; global visits)

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RHC Productivity

Productivity Standards:

• Physician 4,200 visits annually for 1.0 FTE

• Midlevel 2,100 visits annually for 1.0 FTE

Total visits used in calculation of the cost per visit is the greater of the actual visits or minimum allowed (FTEs x Productivity Standard).

NOTE: The cost report productivity standards cannot be manually adjusted. Therefore, if a provider only worked a portion of a year or if the cost report only represents a portion of a year, the FTE should be adjusted accordingly.

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RHC Productivity

Number Minimum Greater ofof FTE Total Productivity Visits (col. 1 col. 2 or

Personnel Visits Standard (1) x col. 3) col. 4 Positions 1 2 3 4 5

1 Physicians 6.87 25,890 4,200 28,854 2 Physician Assistants 2.16 7,500 2,100 4,536 3 Nurse Practitioners 2,100 - 4 Subtotal (sum of lines 1-3) 9.03 33,390 33,390 33,390 5 Visiting Nurse6 Clinical Psychologist7 Clinical Social Worker8 Total FTEs and Visits (sum of lines 4-7) 9.03 33,390 33,390

Example 1 – Visits Equal Productivity Standards

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RHC Productivity

Example 2 – Productivity Standards Are Greater Than Visits

Number Minimum Greater ofof FTE Total Productivity Visits (col. 1 col. 2 or

Personnel Visits Standard (1) x col. 3) col. 4 Positions 1 2 3 4 5

1 Physicians 6.87 16,221 4,200 28,854 2 Physician Assistants 2.16 4,773 2,100 4,536 3 Nurse Practitioners 2,100 - 4 Subtotal (sum of lines 1-3) 9.03 20,994 33,390 33,390 5 Visiting Nurse6 Clinical Psychologist7 Clinical Social Worker8 Total FTEs and Visits (sum of lines 4-7) 9.03 20,994 33,390

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RHC Productivity

Effect on Cost-Per-Visit Greater of Actual Visits or

Productivity Standard Visits

Allowable Costs for Cost-Per-Visit

Calculation RHC Cost-Per-Visit5,798,460$

Example 1 33,390 173.66$ Example 2 20,994 276.20

• Independent RHC – no effect; cost-per-visit limit• Provider-based RHC to a hospital with less than 50 beds,

$102.54 per visit difference• Could affect Medicaid rate yearly or indefinitely

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RHC ProductivityExample 2 – Benchmark Report

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RHC ProductivityExample 2 – Benchmark Report

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Flu and Pneumonia Reimbursement

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Medicare influenza and pneumonia costs are reimbursed on the cost report: • Cost includes staff, vaccine, and overhead costs• These services should not be billed• Listing of Medicare patients must be

included with the cost report submission:˗ Name˗ Medicare number˗ Date of service

• Vaccine invoices are submitted with the cost report • Pneumo/Prevnar vaccinations are reimbursable on the cost report

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Flu and Pneumonia ReimbursementWorksheetB-1/M-4: CALCULATION AND TOTAL OF PNEUMOCOCCAL AND INFLUENZA VACCINE COST

Part I - Calculation of Cost PneumococcalSeasonal Influenza1 2

1 Health Care Staff Cost 537,821 537,821

2Ratio of Pneumococcal & Influenza Vaccine Staff Time To Total HC Staff Time 0.000651 0.006340

3 Pneumococcal & Influenza Vaccine Health Care Staff Cost 350 3,410

4 Medical Supplies Cost - Pneumococcal & Influenza Vaccine 2,981 3,648 5 Direct Cost of Pneumococcal & Influenza Vaccine 3,331 7,058 6 Total Direct Cost of the Facility 581,931 581,931 7 Total Facility Overhead 349,902 349,902

8Ratio of Pneumococcal & Influenza Vaccine Direct Cost to Total Direct Cost 0.005724 0.012129

9 Overhead Cost - Pneumococcal & Influenza Vaccine 2,003 4,244

10Total Pneumococcal & Influenza Vaccine Cost & Its Administration 5,334 11,302

11Total Number of Pneumococcal & Influezna Vaccine Injections 35 341

12 Cost Per Pneumococcal & Influenza Vaccine Injection 152 33

13# of Pneumococcal & Influenza Vaccine Injections Admins To Medicare Beneficiaries - 169

14Medicare Cost of Pneumococcal & Influenza & Its Administration - 5,601

15Total Cost of Pneumococcal & Influenza Vaccine & Its Administration 16,636

16Total Medicare Cost of Pneumococcal & Influenza Vaccine and Its Administration 5,601

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Example – Benchmark Report

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Medicare Bad Debt

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Medicare Bad Debt

• Medicare bad debt reimbursement is 65% of allowable bad debt claimed.

• Allowable coinsurance and deductible amounts only.• Debt must be related to covered services.− Do not include lab, radiology, or other non-RHC services on the cost report.

• Provider must be able to establish that reasonable collection efforts were made.− Document that a reasonable and consistent collection effort has been made

for 120 days from the date of the initial bill to the patient. (CMS is now insisting that if an account is turned over to an outside collection agency, the account cannot be claimed until returned from the collection agency.)

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Medicare Bad Debt

CMS Pub. 15-I Section 308 states the criteria for allowable Medicare bad debt:• Debt must be related to covered services and derived from

deductible and coinsurance.• Provider must be able to establish that reasonable collection

efforts were made.• Debt must actually be uncollectible when claimed as worthless.• Sound business judgment must have been established to

determine there was no likelihood of recovery at any time in the future.

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Medicare Bad Debt

CMS Pub. 15-I Section 310 defines reasonable collection effort:• Similar to effort for non-Medicare patients.• Issuance of bill to responsible party.• May include subsequent statements, collection letters, and

telephone calls.• Referral to collection agency if used for non-Medicare

patients of “like amounts.”

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Medicare Bad Debt

Presumption of noncollectibility, CMS Pub. 15-I Section 310.2:• If after reasonable and customary attempts to collect a bill, the

debt remains unpaid more than 120 days from the date the first bill is mailed to the beneficiary, the debt may be deemed uncollectible.

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Medicare Bad Debt

Indigent Patients, CMS Pub. 15-I Section 312:• Clinics can claim bad debt without waiting the 120-day

collection period.• Determination of indigence must be documented in the

patient’s file.• Beneficiary considered indigent if eligible for Medicaid.• Provider must determine that no other source is legally

responsible for payment.

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Medicare Bad Debt

• Denials by Medicaid as secondary payer, as long as actually billed and denied, can be claimed immediately.

• Documented charity care write-offs can be claimed immediately.• Provider Reimbursement Manual – Part I Chapter 3• https://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021929.html

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Paper-Based-Manuals-Items/CMS021929.html

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Medicare Bad Debt

Documentation Required With Cost Report:• Beneficiary name and HIC number• Date(s) of service• Date of first bill sent to patient• Medicare paid date (R/A)• Write-off date• Separation of deductible and coinsurance

amounts• Medicaid payment and paid date (if any)

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Reimbursement Settlement

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Operational Strategies

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Filing Consolidated Worksheets Rather Than Individual Cost Reports (Per the Medicare Claims Processing Manual, Chapter 9)If RHCs are part of the same organization with one or more RHCs, they may elect to file consolidated worksheets rather than individual cost reports. Under this type of reporting, each RHC in the organization need not file individual cost reports. Rather, the group of RHCs may file a single report that accumulates the costs and visits for all RHCs in the organization. In order to qualify for consolidation reporting, all RHCs in the group must be owned, leased, or through any other device, controlled by one organization.

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The Provider Statistical and Reimbursement System (PS&R) is an essential component of cost report reconciliation• Report summarizes all paid Medicare claims

˗ Visits˗ Charges (including preventive)˗ Deductible˗ Medicare payments

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Helpful Hints

• Collect as much data as possible on an ongoing basis. • Set up accounting procedures to collect as much financial data

in the form and level of detail required for year-end reporting. Use the cost report forms for reference.

• Determine early whether the clinic will need to collect special data for the cost report (e.g., related-party expense).

• Be consistent from year to year.• Use the PS&R report provided by the intermediary to report

Medicare visits, deductibles, and payments.• Review the cost report for reasonableness (e.g., $700 cost per

pneumococcal injection is not reasonable).

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Helpful Hints

Independent Provider-Based

RHC Basic Information (address, provider number, certification date) S S-2/S-8

Expense Information A A/M-1

Reclassifications A-1 A-6

Adjustments A-2 A-8

Related-Party Adjustments A-2-1 A-8-1

Allocation of Overhead (Hospital) - B Part I

Visits and FTEs; Allocation of Overhead to RHC/Non-RHC B, Part I M-2

Influenza and Pneumonia Cost B-1 M-4

Cost-Per-Visit, Medicare Bad Debt, Settlement C M-3

Medicare Payments Entry - M-5

Cost Report Worksheets:

Questions?

Katie Jo Raebel, CPA, Partner Wipfli Health Care [email protected]

Today’s Presenter

PREMIERSPONSOR

PLATINUMSPONSOR

GOLD SPONSORS SILVERSPONSORS

Networking BreakRefreshments are available in Regency Foyer with the Exhibitors

RHC Compliance 101Elsie Crawford

RN, BSN, MSTConsultant

AAAASF

Session Objectives

Participant will learn what the inspector is looking for and what should be avoided.

Participant will experience virtual “walk through” of clinicfrom entrance to exit from the inspector’s perspective.

The participant will understand the basic requirements for obtaining certification as an Rural Health Clinic.

RHC Certification Process Applications are filed with (CMS) and the state after

determining RHC is in a designated shortage area. CMS reviews the application for validity. The state reviews the application forms sent to it. When the full application is determined to be complete, a date is

scheduled for the survey.

RHC Certification Process

The state Medicaid program is informed of the new rural health Clinic.

Interim payment rates are established.

Begin date in the program is generally the date of survey (in the case of no deficiencies) or the date when the deficiencies are remedied and the POC is filed with the state.


If no deficiencies are found, the state forwards its approval to the CMS Regional Office (RO) for final review.

If there are deficiencies, the state sends a letter of deficiencies to the clinic. The clinic responds with a plan of corrections (POC). When the deficiencies are remedied, state approval is sent to the RO.

Preparing for the RHC Certification Survey

Four key elements in the RHC Certification Survey. • Policy and Procedure Manual Review• Medical Records Review• Facility Inspection, and• Program Evaluation.


WHERE THE SURVEY BEGINS:


RHC Policy and Procedure Manual The policy and procedure manual should

cover key human resource policies, administrative policies, clinical procedures and protocols, and medical guidelines per RHC Code of Federal Regulations (CFR) §491.7(a)(2).

Each clinic’s policy and procedures manual should be drafted with that clinic in mind. This document should be an accurate reflection of how the clinic truly intends to operate.


Medical RecordsPolicy to provide patient

confidentiality and safeguard against: loss, destruction, or unauthorized use of patients’ health record.

A representative sample of the clinic’s medical records (Medicare and Medicaid only) will be reviewed.


FacilityPreparing the facility is a

requirement of the RHC program. An inspection of the physical

plant is one of the key elements of the survey process.

Preparing for the RHC Certification Survey Facility

Maintain facility consistent with appropriate State and local building, fire, and safety codes.Have a preventative maintenance

policy.Provisions for the appropriate

storage of drugs and biologicals and premise be clean and orderly.

Appropriate Exit signs and other safety measures.

REQUIRED LAB TESTS.

HGB or HCT

Glucose

Urine Dipstick

Urine Pregnancy Test

Stools for Occult Blood

Culture Preparation


Program EvaluationAn evaluation of the clinic’s

total operation including the overall organization, administration, policies and procedures covering personnel, fiscal and patient care areas must be done at least annually.


THIS EVALUATION MAY BE DONE BY:

THE CLINIC

AN OUTSIDE GROUP OF PROFESSIONAL PERSONNEL THAT INCLUDES ONE OR MORE PHYSICIAN ASSISTANTS, ARNP,AND ONE NON CLINIC STAFF MEMBER.

THROUGH ARRANGEMENTS WITH OTHER PROFESSIONALS.

Preparing for the RHC Certification Survey Program Evaluation (continued)

If operational for a year or more at the time of the survey, there must be an evaluation of its total program.

If operational for less than one year or is in the start-up phase, no evaluation is required. There should be a written plan that specifies who is to do the evaluation, when it is to be done, how it is to be done, and what will be covered in the evaluation.

Preparing for the RHC Certification Survey Program Evaluation

The evaluation is done to determine whether utilization was appropriate; policies were followed; and whether any changes are needed.

The clinic staff or a group of professional personnel must consider the findings of the evaluation and take corrective action if necessary.

Emergency Preparedness

491.12

Emergency Preparedness

491.12 (a) Have an Emergency Preparedness Plan491.12 (b) Policies and Procedures491.12 (c) Communication Plan491.12 (d) Training and Testing491.12 (e) Integrated Health Care System

491.12 (a) Emergency Preparedness Plan

Must be created and reviewed annually

Include analysis of potential emergencies and strategies to respond to the various situations

Plan centered around a facility-based and community-based risk assessment that encompassed an all-hazards approach

Emergency plan should document efforts made to collaborate with Federal, State and local agencies.

491.12 (b) Policies and Procedures Reviewed and updated annually

Must have policies relating to safe evacuation, transportation, exit sign placement, and staff responsibility

A means to shelter must be established

Preservation of patient information.

Policy on the use of volunteers in a emergency

491.12(c)Communication Plan

Contact information for ALL staff.

Contact information for local emergency management agencies.

Primary and secondary means of communication.

Plan to communicate clinic’s condition and ability to provide care in an emergency.

Ability to provide location of patients (if shelter in place)

491.12 (d) Training and testing

All staff must trained on the emergency plan

One documented training per year for all staff

One full scale community-based exercise per year

An additional full-scale exercise OR tabletop exercise per year

Actual event will suffice.

The clinic has an emergency preparedness program that addresses an emergency on-site, off-site (natural disaster) and disruption of services. 491.12

The clinic complies with all applicable Federal, State and local emergency preparedness requirements.

The clinic has an emergency preparedness plan that is reviewed and updated annually. It is a documented, clinic-based and community-based risk assessment that utilizes an all hazards approach.

Strategies for addressing emergency events identified by the risk assessment

The clinic has an emergency preparedness program that addresses an emergency on-site, off-site (natural disaster) and disruption of services. 491.12 (CONT)

Addresses patient population, vulnerable patients.

Services the clinic can provide in an emergency.

Continuity of operations. Delegation of authority and succession

plans. Collaboration with ALL emergency

preparedness officials for an integrated emergency response.

The clinic has developed and implemented emergency preparedness policies and procedures that are based on its emergency preparedness plan. (42 CFR 491.12(b))

Safe evacuation from the clinic, which includes appropriate placement of exit signs.

Staff responsibilities and needs of patients A means to shelter in place for patients,

staff, and volunteers who remain in the clinic

The clinic has developed and implemented emergency preparedness policies and procedures that are based on its emergency preparedness plan. (42 CFR 491.12(b))

Medical documentation that preserves/protects patient information and confidentiality.

Secures and maintains the availability of patient health records

Staff responsibility and use of volunteers.

The process to integrate State or Federal designated health care professionals to address surge needs.

How refrigerated/frozen medications such as vaccines, etc. are handled in a power outage

The clinic develops and maintains an emergency communication plan that complies with Federal, State and local laws. (42 CFR 491.12 (c))

The clinic’s communication plan includes the following elements;

Names and contact information for ALL Staff. Include those under arrangement, physicians, Other RHCS, Volunteers.

Contact information for the regionalandlocal emergency management agencies.

Primary and alternate means for communication.

The clinic develops and maintains an emergency communication plan that complies with Federal, State and local laws. (42 CFR 491.12 (c))

A communication plan for internal and external emergencies.

A method to communicate condition and location of patients.

Ability to provide information about the clinic’s needs and ability to provide assistance.

How employees will be notified of the emergency.

Staff responsible for calling the Fire Department

Location to meet outside the building.

Staff person responsible for head count after evacuation.

Staff responsible for notification and triaging of patient services.

Contingency plan that includes alternative provider if the clinic can not service its own patients.

Training Program: The clinic develops and maintains an emergency preparedness training and testing program that is based on the emergency preparedness plan, risk assessment, policies and procedures, and the communication plan. (42 CFR 941.12(d)(1))

The training and testing program is reviewed and updated, at minimum, annually.

Initial training is furnished to all new staff.

The training program includes all the following

Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles

Provide emergency preparedness training, at a minimum, annually

Emergency preparedness training of staff, individual providing service under arrangement, and volunteers is documented. This documentation demonstrates knowledge of emergency procedures

Testing Program: The clinic conducts exercises to test the emergency plan, at minimum, annually. (42 CFR 491.12(d)(2))

Participate in a full-scale exercise that is community-based.

When a community-based exercise is not assessable, an individual, facility-based.

If the clinic experiences an actual, or man-made emergency that requires activation of the emergency plan, the clinic is exempt from engaging in a community-based or individual, facility-based full scale exercise for 1 year following the onset of the actual event.

Testing Program: The clinic conducts exercises to test the emergency plan, at minimum, annually. (42 CFR 491.12(d)(2))

Conduct a second full-scale exercise that is community-based or individual, facility-based

A tabletop exercise that includes a group discussion with a clinically relevant scenario.

Evaluate the clinic’s responses to and maintain documentation of all drills, tabletop exercises, and emergency events.

Revise the clinic’s emergency plan, as needed.

If the clinic is part of a healthcare system consisting of multiple separately certified healthcare facilities elects to have a unified and integrated emergency preparedness program, the clinic may choose to participate in the healthcare system’s coordinated emergency preparedness program. (42 CFR 491.12(e))

Demonstrate that each facility within the system actively participated in the development of the unified and integrated emergency preparedness program

Be developed and maintained specifically for each clinic.

Demonstrate that each separately certified facility is capable of actively using the unified and integrated emergency preparedness program and is in compliance with the program.

What Happens After the Survey

When the Certification Survey results in no deficiencies, the State agency has ten (10) calendar days to prepare the Survey Packet for the CMS Regional Office (RO) with a recommendation of approval

The RO has 60 days to review and approve the survey packet and issue the Medicare Provider Letter to the clinic. For those clinics that file their application as a Provider-based entity, the provider-based request must be submitted to the RO with the survey packet. The RO will make the Provider-based determination and will notify the appropriate Fiscal

Intermediary via the Medicare Tie-In Notice.


Should the survey result in deficiencies or citations, a Statement of Deficiencies will be sent to the clinic by the State agency within ten (10) days of the survey.

The clinic will have 10 days to develop a Plan of Correction (POC) and submit the POC back to the State agency for approval.

Common Deficiencies Lack of preventive maintenance

program

Inadequate staff emergency training

Inadequate policies and procedures or policies and procedures not developed according to regulations

Providers not taking on required responsibilities

Lack of appropriate medical records

Evaluation not performed according to regulations


Key elements to a POC include: it must be doable or realistic, it must have completion dates, it must specifically address the citation, and if appropriate, the clinic must be able to document proof of compliance. There are no time constraints placed on the

State agency when reviewing a POC. Once the State agency has found the POC to

be acceptable, they will submit the survey packet with recommendations to the RO.

The RO has 60 days to review and approve the survey packet and issue the Medicare Provider Letter to the clinic.

QUESTIONS ?

Presenter:Elsie Crawford

(423)784-7260 x3104

[email protected]

mailto:[email protected]

LUNCHProvided in

Rio Grande Ballroom &Garden Terrace (1st floor)

Sessions resume at 1:00 p.m.Lunch table assignments are under your profile

in the attendees module of the app.

Shift Your Clinic Culture to Create aHigh Performing Staff

Jeff HarperPrincipal, Consultant, Coach

InQuiseek

Learning Objectives

Elements of a High Performing Staff

The Buzzword, Culture, what is it and how does it relate to RHCs

Steps to shift the Culture and why our survival depends on it.

Marks of a high performing staff

Patientengagement is constantly

improving.

High Volumesare welcome

Cross Trainingjust happens

Moraleis high.

Strengthsare known and used

Work-a-roundswhen schedule has issues

No Peckingorder, all are equally 2nd

Technologynot fighting it but using it

Marks of a high performing team con’t.

Gossipis not rewarded

Everyoneknows where the broom is located

Leadershipknows who works for whom

Where is this team?in a healthy culture

Marks of a high performing team con’t

Culture: What is it?

Wrong Definition 2the customary beliefs, social forms, and material traits of a racial, religious, or social group

Well, its not in thepetri dish. Or underhere.

Wrong Definition 1Cul-ture/ˈkəlCHər/noun

the arts and other manifestations ofhuman intellectual achievement

Culture: What is it? Right Definitioncul·ture/ˈkəlCHər/noun

the set of sharedattitudes, beliefs, goals, and behaviors thatcharacterizes an institution or company

Here, we are talking about this definition:

Createbut they’re powerful

Good Behavior is a by-product

Beliefsaren’t seen

Attitudesare

contagious

BehaviorsThis is what we

want.

Manifest in

We want Behaviors to Change but How?

To change behaviors, you must change beliefs.

But, beliefs are changed by observing behaviors.

Beliefs are usually caught, not taught.

Modeledusually by the provider(s)

Drivenor by other leaders

PracticedBut, not always

am I am I

am Iam I

ProviderHeal thyself!

CEOLook in the mirror!

ManagerGet the log

out of you eye first!

AssistantBe truthful about

yourself!

What comes 1st? We want a High Performing Team

Cognitive

Resources

Motivation

Politics

Areas of Challenge

One colleague at a time

Now that you have addressed YOURbehavior, we can work with the team.

Start with the providers first – thosewith the most influence.

Determine where are their pain pointsand address them.

Interview the team one by one,privately

Sample Questions for the TeamWhat could we do to make our patients notice that our culture is changing? If you were in charge

what would be the 1st thing you would do to shift our culture?

Take notes & Save them

Make it their idea

Compliment Compliment Compliment

Praise things that don’t need to change

Preach the vision & use words if you have to

Any advance deserves a party

Look for an ally & get close to enemies

We need buy-in Momentum is needed

½ to 1½ days

QuarterlyStrategy is developed here; Team building; bettering relations

1:15-1:30 min

Brain storming; celebrations; new projects

Monthly

5 to 10 min

DailyStanding; check-in;

news of day; kid’s homerun

30-40 min

Weeklyculture lunch;

review & help w/ culture projects

Meeting Schedule now meeting with the team or staff

Why is our survival contingent on culture change?

Life

Death

or

Convenience is now the King

What can we do to make our patient’s encounter more convenient?

patron’s

What can we do to our waiting room to improve their experience?

welcome center

Conditions they treat include:•Flu or cold•Cough•Conjunctivitis (Pink eye)•Low grade fever•Possible sinus infections•Skin rashes•Swimmers ear•And more

Look who wants our profitable encounters

• You can shop while you wait.

• Our hours match your schedule.

• We accept walk-ins.• We have a doctor waiting

on your telemedicine call.• Pick your own appointment

slot with your smart phone.

What’s their strategy? How are they going to compete?

BM&Y, We better shift our culture…

What’s our Strategy? What’s our secret weapon?

StarbucksCan’t help us

ShoppingWon’t work

Secret SauceWe can care more; We can treat patrons like they are #1.

If providing service, giving respect, dispensing dignity, and esteeming others is our culture, we have the “secret sauce” to compete with any of those guys.

Can you shift your Culture? Yes you can!High Performance here we come

We got this!

Jeff [email protected]

318.243.5974

mailto:[email protected]

Emergency Preparedness in Rural Settings

Nicole Peace CoarseyMPA

Louisiana Primary Care OfficerLouisiana Department of Health

Objectives

• Create scenarios that are feasible & relevant to rural areas • Developing a full-scale or TTX exercise with limited resources• Learn how to get the most out of your exercises • Develop active shooter scenarios

Why Exercise?

Why Exercise?

Because CMS tells us we have to!

Why Exercise?

• Challenge and examine plans• Identify important training and skills gaps• Can sharpen group problem-solving under pressure• Elevate your facilities level of preparedness• Pinpoint resource needs

Why Exercise?

Training and testing. “The RHC/FQHC must develop and maintain an emergency preparedness training and testing program that is based on the emergency plan …”

https://narhc.org/resources/rhc-rules-and-guidelines/#emergency


Why Exercise?

Training• Initial training• Training conducted annually• Document training



Why Exercise?

Testing: Must conduct exercises to test the emergency plan at least annually1. Participate in a full-scale exercise that is

community-based• Not accessible, conduct an individual, facility-based exercise

2. Conduct an additional exercise • Second full-scale exercise that is community-based or

individual, facility-based• Tabletop exercise


DIY ExerciseCreate scenarios that are feasible & relevant to rural areas, while getting the most out of the exercise using very few resources.

Exercise Types

• Tabletop Exercise (TTX): A tabletop exercise involves key personnel discussing simulated scenarios in an informal setting. TTXs can be used to assess plans, policies, and procedures.

• Drill: A drill is a coordinated, supervised activity usually employed to test a single, specific operation or function within a single entity (e.g., call down your staff).

• Full-Scale Exercises (FSE): A full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional (e.g., joint field office, emergency operation centers, etc.) and “boots on the ground” response (e.g., relocate vaccine during a mock power outage).

Design your Exercise

• Clarify Objectives and Outcomes. Be clear about what you hope to achieve during the exercise. However, deciding how you will use the results after the exercise is over is even more important.

Exercise Goals

1. Reveal planning weaknesses in the Emergency Operations Plan and standard operating procedures.

2. Test recently changed shelter in place procedures. 3. Improve the coordination between and among various response

personnel. 4. Identify deficiencies and validate training on the critical

elements of emergency response.5. Increase the general awareness and understanding of the

potential hazard.



• Choose the Right Participants and Exercise Team. Assemble the staff who manage actual emergencies to be your players. You want the key decision-makers in the room.



• Choose the Right Participants and Exercise Team. Assemble the staff who manage actual emergencies to be your players. You want the key decision-makers in the room.

• Design an Interactive Scenario. Create a solid, believable scenario that meets your objectives, but don’t get hung up on it. Time is better spent designing great questions, a detailed game plan, and an approach that will engage all players in an interactive dialogue.

Select the Perfect Scenario

• Look at the results of your HVA• Rotate the hazard you test• Google is your friend!

Remember what CMS wants you to be able to do:“Demonstrate staff knowledge of emergency procedures.”


Active Shooter Event

Date: Friday, February 19Time: 11:00am ESTA member of your front office, who has been with your clinic for eight years, has just had his employment terminated. As he is escorted out of the building by security, he tells them they will regret treating him like this.

Engage• Create an Interactive, No-Fault Space. Avoid the stiffness of a TTX by

creating an environment that builds trust and encourages discussion. Declare the venue a “no-fault zone” to allow people to ask any question and make mistakes. Design the physical space to stimulate interaction. Engage all players and help them think through the series of actions that will get the best outcome.

• Ask Probing Questions to Gain Insight. Use an experienced facilitator who can uncover key issues and discern valuable insights. Follow a good script but be flexible and responsive to the conversation. Know where to probe for additional information.

• Capture Issues, Lessons, and Key Gaps. Don’t just rely on teams of notetakers; capture and review key points in real-time during the exercise. Use visual tools and a timeline to see how decisions unfold as an event escalates.

Discuss

• Who should be informed of this behavior?• What concerns might you have?• What actions would you consider taking, if any, at this

stage?

Learn

• Prepare an After-Action Report. Document the exercise and next steps in an AAR. Make it stand out with clear diagrams, lists of best practices, opportunities for improvement, and lists of resources. Make it useful and readable; don’t make it an AARRRGH!

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Templates-Checklists.html

https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertEmergPrep/Templates-Checklists.html

How to get the most out of your exercise

• Conduct the exercise during a staff meeting• Work with another RHC or FQHC to conduct the exercise

together• Take it from a tabletop to a drill!

• Tabletop Exercise (TTX): A tabletop exercise involves key personnel discussing simulated scenarios in an informal setting. TTXs can be used to assess plans, policies, and procedures.

• Drill: A drill is a coordinated, supervised activity usually employed to test a single, specific operation or function within a single entity (e.g., call down your staff).

Why not a full-scale?

• Full-Scale Exercises (FSE): A full-scale exercise is a multi-agency, multi-jurisdictional, multi-discipline exercise involving functional (e.g., joint field office, emergency operation centers, etc.) and “boots on the ground” response (e.g., relocate vaccine during a mock power outage).


Virtual Tabletop Exercise Series

Nicole Peace Coarsey, MPALouisiana Department of Health

Office of Public HealthBureau of Primary Care and Rural Health

Louisiana Department of Health in partnership with the

Louisiana Rural Health Association

General Ground Rules

• This exercise is being conducted via a webinar. You will be provided a scenario and are expected to discuss your facilities activities during the allotted time.

• The facilitator will randomly call upon facilities to share what was discussed.• Your microphone will be muted by the facilitator until called upon.• Use the “Raise Hand” feature to speak to the entire group.• Use the “Chat” feature if you want to type a question or make any comments.• We understand that you represent different types of facilities and at different

locations throughout the country. Respond to the scenario as if your facility was being affected.

• A scenario will be presented followed by related questions. Take notes on the handout provided. These notes can be used to develop your After Action Report/Improvement Plan documentation. The more you are engaged during this exercise, the better your final product will be.

Exercise Goals

• Discuss a hazard-specific scenario to determine how your facility would respond during the event, paying special attention to your emergency response plan, capabilities, and staff responsibilities.

• Identify any weaknesses in your plan, consider the best ways to respond to your employees’ and patients’ needs, and ensure the facility is operational as soon as possible after the event.

• Debrief after the scenario to improve your response to emergencies and disasters and trouble shoot any other unresolved questions.

Exercise Objectives

1. Reveal planning weaknesses in the Emergency Operations Plan and it standard operating procedures or to test or validate recently changed procedures.

2. Identify current capabilities. 3. Improve the coordination between and among various response

personnel. 4. Identify deficiencies and/or validate training on the critical

elements of emergency response.5. Increase the general awareness and understanding of the

potential hazard.

Active Shooter By Definition…

• An individual actively engaged in killing or attempting to kill people in a confined & populated area

• Active shooter situations are unpredictable & evolve quickly • Typically, immediate intervention of law enforcement is required

to stop the shooting & mitigate harm or death to victims • Active shooter situations are often over within 10 to 15 minutes • Staff should try to be prepared both mentally & physically to deal

with an active shooter situation

Mentality of an active shooter

• Desire is to kill and seriously injure without concern for his safety or threat of capture.

• Generally has intended victims and will search them out. • May accept targets of opportunity while searching for or after finding

intended victims. • Will continue to move throughout building/area until stopped by law

enforcement, suicide, or other intervention. • Shooters will often times create chaos along the along the way as part of

their plan, such as placing explosives or pulling fire alarms as they move through buildings

• Most take their own life when confronted by Law Enforcement or resistance

As Clinic Employees, How to React

• Evacuate if there is an accessible escape path• Escort patients out with you if possible• Leave your belongings behind• Prevent individuals from entering an area where the active shooter may

be• Follow the instructions of any police officers• Do not stop to assist wounded people• Do not attempt to move wounded people• Call 911 when you are safe

Where to hide if you can’t get out?

• Get out of the active shooter’s view• Silence cell phones, radios & televisions• Provide protection if shots are fired in your direction (i.e., an

office with a closed & locked door)• Do not trap yourself or restrict your options for movement• To prevent an active shooter from entering your hiding place, lock

door or blockade door with heavy furniture

What to Expect When Law Enforcement Arrives

• Law enforcement’s purpose is to stop the active shooter as soon as possible• Officers will proceed directly to the area in which the last shots were heard• Officers usually arrive in groups of two or more• Officers may wear regular patrol uniforms or external bulletproof vests, Kevlar

helmets, other tactical equipment, street clothes• Officers may be armed with rifles, shotguns & handguns• Officers may use pepper spray or tear gas to control the situation• Officers may shout commands, & may push individuals to the ground for

everyone’s safety• The first officers to arrive to the scene will not stop to help injured persons

How to React When Law Enforcement Arrive

• Remain calm, & follow officers’ instructions

• Put down any items in your hands (i.e., bags, jackets)

• Immediately raise hands & spread fingers

• Keep hands visible at all times

• Avoid making quick movements toward officers

• Avoid pointing, screaming and/or yelling

• Proceed in the direction from which officers are entering the premises

• Stay in safe place until instructed otherwise

START OF EXERCISE

Discuss

• Who should be informed of this behavior?• What concerns might you have?• What actions would you consider taking, if any, at this

stage?

Update

Date: Monday, April 5Time: 9:15 am ESTA popping sound is heard within the building. An employee runs into your office shouting that there is a man firing a gun in the hall.

Discuss

What actions should you take?How are you communicating with employees? With

patients? Who is communicating?Who is in charge of the situation?• Who is responsible for contacting law enforcement?

• What information do you relay to them?

Update

You decide to shelter in place in an office, and secure the immediate area. The popping noises seem to be coming from your floor. There is yelling and screaming outside your door.A patient (with her child) knocks frantically on your door pleading to be let in.

Discuss

• What action will you take to ensure your office remains secure?

• What will you do about the patient and her child outside your door?

• What additional concerns do you have at this time?• Are you able to communicate with employees?

Update

You hear someone attempting to open the door, then several loud shots. After a few minutes of silence, it appears that the shooter may have moved on. For nearly an hour there is no sound from outside your door. Employees are receiving calls from family members who have learned of the active shooter in your building. Emergency personnel can be seen outside. The patient tells you she wants to leave your office.

Discuss

• What are your immediate concerns at this time?• What do you tell the patient sheltering in place with you?• Who is responsible for deciding when it is safe to leave

the secure area?

Update

Law enforcement personnel arrive outside your office door and direct you to evacuate the building.Upon evacuation, your employees are cornered by news reporters asking about the experience. Some employees do not have their car or house keys and are concerned about getting home.

Discuss

• How will you account for patients? Employees?• How will family members be contacted? • How do you prepare your employees for the disturbing scenes they may

encounter as they evacuate?• Who is responsible for communicating with law enforcement?• Who is responsible for communicating with news media?

• What information will you give them?• Can you control who else the media approaches? If not, what can you do?

• How will your employees get home?• Will you request access back into the building? Who would go in?

Update

The shooter has been apprehended by law enforcement.There has been one death (an employee) and several injured.The building is designated a crime scene and is closed for a week.

Discuss

• Who initiates business continuity plans?• What else needs to be considered?• How is information disseminated to employees? To

patients?

Update

Date: Monday, April 12 You are able to get back into the building and resume normal business operations. Several employees ask for more time to emotionally recover from the event.

Discuss

• Are you able to continue normal business operations using fewer staff?

• How will you accommodate individuals who have been emotionally traumatized by the event?

• What resources will you make available to staff? To patients?

• How will you communicate your clinic’s resilience to concerned clients?

END OF EXERCISE

Hot Wash

1. What strengths in your workplace’s emergency plans did this exercise identify?

2. What weaknesses in your workplace’s emergency plans did this exercise expose?

3. What unanticipated issues arose during the exercise? 4. What gaps were identified? 5. What are some high-priority issues that should be addressed? 6. What are some new ideas and recommendations for

improvement?

Next Steps

• Now that you have completed your Tabletop Exercise (TTX) for an active shooter, consider these additional action items:

• Compile all notes taken during this exercise• Gather staff at your respective facility to discuss gaps in your plan• Draft an AAR/IP report on results from TTX

• Provided in the Handouts section of the Webinar with directions• Assign leads within the organization to address gaps• Communicate the steps you are taking to your entire organization

Next Steps

• If you don’t have a plan:• Complete a Hazard Vulnerability Analysis

• Provided in the Handouts section of the Webinar• Utilize the emergency operations plan template

• Provided in the Handouts section of the Webinar

Nicole Peace Coarsey, [email protected]

Objectives

• Create scenarios that are feasible & relevant to rural areas • Developing a full-scale or TTX exercise with limited resources• Learn how to get the most out of your exercises • Develop active shooter scenarios

Questions?

• Go to Google Drive for all documents• https://drive.google.com/drive/folders/1utWg-

ZZQu4OrbylB8s_WcHGUrTWeD3_p?usp=sharing • Contact Nicole Peace Coarsey for other exercise scenario

documents• Register for Virtual Tabletop Exercises

Breakout SessionsReturn for

Top 10 Documentation Concerns in the RHC

Sharon Shover

Go to Rio Grande for

Commingling: Clinic Layout & Compliance

Charles James Jr

OR

PREMIERSPONSOR

PLATINUMSPONSOR

GOLD SPONSORS SILVERSPONSORS

Networking BreakRefreshments are available in Regency Foyer with the Exhibitors

Top 10 Documentation Concernsin the RHC

Sharon ShoverCPC, CEMC

Manager Reimbursement & Payor RelationsIndiana Hospital Association

Common Documentation #1

New Patient or Established Patient

• A new patient is one who has not received any professional services from thephysician/qualified health care professional or another physician/qualified health careprofessional of the exact same specialty and subspecialty who belongs to the same grouppractice, within the past three (3) years.

• An established patient is one who has received professional services from thephysician/qualified health care professional or another physician/ qualified health careprofessional of the exact same specialty and subspecialty who belongs to the same grouppractice, within the past three (3) years.

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What is Diagnostic Medical Care?

Diagnostic medical care involves treating or

diagnosing a problem you’re having by

monitoring existing problems, checking out

new symptoms or following up on abnormal

test results.

What is Preventive Care?

Preventive care includes

immunizations, lab tests, screenings and

other services intended to prevent illness or

detect problems before you experience any

symptoms.


Timely

• Medicare expects the documentation to be generated at the time of service or shortlythereafter. Delayed entries within a reasonable time frame (24 to 48 hours) are acceptable forpurposes of clarification, error correction, the addition of information not initially available,and if certain unusual circumstances prevented the generation of the note at the time ofservice.

• The CMS IOM does not provide any specific period to reflect “as soon as practicable,” however,WPS GHA medical directors would offer a reasonable time frame of 24-48 hrs.

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Physician Authentication

• A provider may not submit a claim toMedicare until the documentation iscompleted. Until the practitionercompletes the documentation for aservice, including signature, thepractitioner cannot submit the serviceto Medicare. Medicare states if theservice was not documented, then itwas not done.

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247

• Templates

–Check boxes for ROS Compare narrative HPI to CC–Automatically pulling forward PFSH from a previous visit– Inconsistent documentation HPI to examination–Ancillary Services Medical necessity–Cloning Review of Systems–Cloning Examination


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Medical necessity of a service is the overarching criterion for paymentin addition to the individual requirements of a CPT code. It would notbe medically necessary or appropriate to bill a higher level of E&Mservice when a lower level of service is warranted. The volume ofdocumentation should not be the primary influence upon which aspecific level of service is billed. Documentation should support the levelof service reported.


• 491.10 – Records System – Informed Consent

–Name of the specific procedure(s)–Practitioner who is performing the procedure(s)–Statement that the procedure, benefits, material

risks, and alternative therapies, was explained to the patient.

– Signature of the patient or the patient’s representative; and

–Date and time the informed consent is signed by the patient.

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250

Code to highest level of specificity

Code for chronic conditions

Code for population acuity

Code all documented conditions which coexist at the time of the visit that require or affect patient care or treatment

If the condition is mentioned in the past medical history but is not addressed at this visit, don't report it.

When no diagnosis has been established for an encounter, code the condition or conditions to the highest degree of certainty, such as symptoms, signs, abnormal test results, or other reason for the visit.

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://cliparts.co/office-building-clipart&ei=21xfVZSFMNGHyASG6IFw&psig=AFQjCNE11vjJOfK_FAdNd5p8w1revzIoGw&ust=1432399446629327




Location of impacted cerumen

1

Instrumentused

2

Method of removal

3

Time and effort

4

Patient instruction given and outcome

5

Ear Wax Removal


Sample medications are not documented:

• Name and strength of the drug

• Lot number of the drug

• Patient specific directions for use of the drug (or Pharmacy-generated druginformation sheets)

• Expiration date of the drug

• Documentation for injections must reflect the drug, dosage, frequency, method, andsite of administration.

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Common Documentation #11CPT 99211 should not be used:

• Office visit for an established patient with long standing allergic rhinitis who receives the monthly maintenance allergy injection.

• Office visit for an established patient with Pernicious Anemia who has no complaints and is given a monthly Vitamin B-12 injection.

• Office visit for a established patient who presents solely to have a routine blood pressure check, which is recorded in the chart.

• Office visit for an established patient with a previous stroke who comes to a clinic staffed by a lab technician. Flow sheet records the date, prothrombin time, INR and Coumadin dosage.

253


Individual Psychotherapy missing time

• Billing for 90834, psychotherapy, 45 minutes with patient and/or family member

• Missing the "in & out" times or the total time spent in each individual psychotherapy session with the patient and/or family member.

254


Counseling and/or Coordination of Care

• When counseling and/or coordination of caredominates greater than 50% of the encounter (face-to-face time in the office or other outpatient settingfor floor/unit time in the hospital or nursing home),then time shall be considered the key or controllingfactor to qualify for a particular level of E&M service.

• Documentation should reflect the extent ofcounseling and/or coordination of care.

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Lack of Advanced Beneficiary Notice (ABN)

An ABN is a written notice from Medicare (standard government form CMS-R-131),given to a patient before receiving certain items or services:

• Medicare may deny payment for that specific procedure

• Patient will be personally responsible

for full payment if Medicare denies

payment.

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Common Documentation

#15

Lack of MSP Form

• Medicare Secondary Payer (MSP) is the term used when another payer is responsible for paying a beneficiary's claims before Medicare pays.

• This form protects and preserves the Medicare Trust Fund by ensuring that Medicare benefits are coordinated with all other appropriate payers and Medicare pays only when and what it should pay.


Order Management Differences

• Billed 85025 for CBC with differential.

• Submitted physician's progress supports intent to order CBC without differential.

• These codes are:

–85025 - Complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count.

–85027 - Complete (CBC) automated (Hgb, Hct, RBC, WBC and platelet count)

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Common Documentation #17Hospital Discharge

• Submitted hospital discharge visit, billed as 99239 (hospital discharge day management; more than 30 minutes).

• Missing physician's documentation of time spent on discharge services for billed date of service.

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• Prolonged Time

• An office patient presents during an acute allergic reaction, and the provider performs a 15-minute visit at the 99213 level, during which a steroid injection is administered and the patient is instructed sit in the waiting area for 45 minutes before being re-evaluated.

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Common Documentation #19• Pelvic exam must include 7 of the 11 elements:

– Inspection and palpation of breasts for masses or lumps, tenderness, symmetry, or nipple discharge

– Digital rectal exam including sphincter tone, presence of hemorrhoids and rectal masses– External genitalia (e.g. general appearance, hair distribution or lesions)– Urethral meatus (e.g. size, location, lesions or prolapse)– Urethra (e.g. masses, tenderness or scarring)– Bladder (e.g. fullness, masses or tenderness)– Vagina (e.g. general appearance, estrogen effect, discharge lesions)– Cervix (e.g. general appearance, lesions, or discharge)– Uterus (e.g. size, contour, position, mobility, tenderness, consistency, descent or support)– Adnexa/parametria (e.g. masses, tenderness, organomegaly, nodularity)– Anus and perineum

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Initial Preventive Physical Exam

• Common Missing Elements

–Medications and Supplements (including calcium and vitamins)

–Diet–Opioid Discussion (if applicable)–Visual Acuity Screen–End of Life Planning – Acceptance–Educate, Counsel and Refer

Questions? Contact me!

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