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Provider Based Clinics andRural Health ClinicsPayment Methodologies& Reimbursement IssuesJohn WaltkoSam ChambersCheryl McGee-Waltko
CAHs and Clinics Which setting services the community Which structure satisfies? Community Doctors Minimizes costs Adequate reimbursement What are reimbursement issues? Medicare utilization by clinic/ RHC Emergency Room staffing Physician contracts/arrangements
Reimbursement Objectives Minimum use of ER staffing companies At minimum ER staffing contract should berevised/reviewed for “stand by” time studyrequirements Compensate local physicians at lowestpossible net costs Arrange and design contracts to allowfor reasonable reimbursements toavoid cost reporting issues
Payment MethodologiesPhysicianReimbursementServiceHospital Reimbursement Freestanding Clinic Fee Schedule All Reimb. via PhysicianFee Schedule Provider-BasedClinic Fee Schedule(Reduced) Cost Based Reimb. Rural Health Clinic Fee Schedule forSome Services Cost Based Reimb.Productivity LimitCost per Visit CapPhysician Comp.Allowable Cost
Reimbursement Issues Reimbursement Hierarchy Rural Health Clinic— Provider Based Clinic —high reimbursement Free Standing Cliniclowest, generally—highest reimbursementWild Cards Ancillary Services, provided by clinics Medicaid payments/reimb. Medicaid may not recognize PBCs Medicaid rates for RHCs
Payment for Physician ServicesResource-Based Relative Value Scale(RBRVS) Payment Methodology Relative Value Unit (RVU) - Separatecomponents for:Work Practice Malpractice Each RVU component is updated by aseparate Geographic Practice Cost Index(GPCI) for the area. The weighted average of the three GPCIs iscalled the Geographic Adjustment Factor(GAF)
Payment for Physician ServicesFreestanding Clinic:CPT-4 Code: 99212RVUGPCIProductWork.451.010.454Practice nversion FactorMedicare Payment 38.2581 36.80
Payment for Physician ServicesProvider-Based Clinic:CPT-4 Code: 99212RVUGPCIProductWork.451.010.4545Practice nversion FactorMedicare Payment 38.2581Part B Services 24.86
Payment for Physician ServicesProvider-Based Clinic in CAH:CPT-4 Code: ity ChargeTotal ChargesPayment for Prof. RBRVS –ServiceMedicare PortionHospital Payment (50.00 x CCR)for TechnicalProvider-Based 100.00 50.00NA 50.00 100.00 100.00 36.80 24.860Costs
Provider-Based ClinicsReimbursement in CAHClinic Direct CostsNurses, Receptionist, etc. Hospital Overhead CostsAG, Housekeeping, Depreciation Total Overhead Costs Total Clinic Charge Cost to Charge RatioxMedicare ChargeClinic Facility Charges Only!!Facility Charge Medicare Reimbursement Clinic is ancillary department on cost reportPhysician still bills Medicare carrierNon-Medicare patients carrier billed at full rates as “Physician” services
Provider-Based Rural HealthClinic Reimbursement in CAHClinic Direct CostsNurses, Receptionist, etc. Hospital Overhead CostsAG, Dept., Housekeeping PA & Physician Compensation Total Clinic CostsSubject to “Productivity” Limit Total VisitsAll PA & Physician Visits Cost per VisitxMedicare Visit Medicare ReimbursementCovered Visits OnlyExclude Cost for Part B Billing
ClinicsProvider Based Clinics:Regulatory Requirements
Provider-Based Designation History of Medicare Rules Nodefinition before 1996 1996Program Memorandum A-96-7
Provider-Based Designation(Continued) Final OPPS Rule Focus- same basic issues Hospital department More complex and stringentOther Regulatory Changes BBRA / BIPANow SelfAttestation Application
Provider Based Designation Per FY’03 Inpatient PPS FinalRule: ImplementationC/R’s beginningon/after July 1, 2003 Applications May apply using a self-attestationprocess CMS recommends full, formalapproval Criteria relaxed for joint ventures andmanagement contracts No retroactive recoupment if laterfound to not meet criteria
Not Applicable to Ambulatory surgical centers (ASCs) Comprehensive outpatient rehabilitationfacilities (CORFs) Home health agencies (HHAs) Skilled nursing facilities (SNFs) Hospices Inpatient rehabilitation units that areexcluded from the inpatient PPS foracute hospital services
Not Applicable to Independent diagnostic testing facilitiesfurnishing only:Services paid under a fee schedule, Clinical diagnostic laboratory tests or both. Facilities furnishing only outpatientphysical, occupational, or speechtherapy, as long as the 1,500 annualcap remains suspended. 1,500 cap does not apply to hospital O/Pdepartments Does apply to those operating as part of aCAH
Not Applicable to ESRD facilities Overhead or support departments (i.e.laundry, medical records) Ambulance servicesIn general, if there’s no difference inreimbursement, there’s no need to seekprovider-based status
Definitions Main provider A provider that creates or acquires anotherentity to deliver additional health careservices under its name, ownership, andfinancial and administrative control.On-Campus 250 yards from “main buildings” Exceptions on a case-by-case basisProvider A hospital
Definitions Provider-based entity Createdor acquired by a mainprovider for the purpose of furnishinghealth care services of a differenttype from those of the main providerunder the name, ownership, andadministrative and financial controlof the main provider. Includes both the specific physicalfacility and the personnel andequipment needed to deliver theservices at that facility.
Provider Based Regulations 42 CFR 413.65 (CCH ¶4306) Requirements for all provider-basedentities: Operate under the same license as the mainprovider, unless: Entity can be licensed separately State requires separate license, or does notallow the entity to be included underhospital’s license Share integrated clinical services
Provider Based Regulations Requirements for all providerbased entities (Continued): Integratedclinical services Medical staff has privileges at mainprovider Clinical oversight is the same as for allother clinical departments of mainprovider Medical records “integrated into aunified retrieval system (or crossreference) of the main provider.” CMS says,“Practitioners in either locationcan obtain relevant information about carein the other setting.”
Provider Based Regulations Requirements for all providerbased entities (Continued): FinancialIntegration Entity is a department or cost centeron main provider’s books Shared income and expenses
Provider Based Regulations Requirements for all providerbased entities (Continued): PublicAwareness Entity must be held out to the public aspart of the main provider. Must beobvious to the patient that they’re inhospital space. Signs, letterhead, bills, etc. must showmain provider’s name.
Provider Based Regulations Off-campus entities Off-campusmeans located morethan 250 yards from “main buildings”of main provider Off-campus sites that provide thesame services as a physician officeare assumed to be freestanding Must meet same requirements ason-campus, plus additionalrequirements
Provider Based Regulations Off-campus entities (Continued) Ownershipproviderand control by main 100% owned by the main provider Can’t be owned by parent or sister corp. Same governing body Same organizational documents(bylaws) Main provider has final responsibility foradministrative decisions, contracts,personnel actions, personnel policies,and medical staff appointments
Provider Based Regulations Off-campus entities (Continued) Administrationand supervision Same reporting relationship as otherdepartments: Direct supervision by main provider Same monitoring, oversight, reportingrelationship as other provider departments Accountable to the governing body of themain provider, in the same manner as anydepartment head of the provider
Provider Based Regulations Off-campus entities (Continued) Administrationand supervision Integration of administrative functions Billing, records, human resources, payroll,employee benefit package, salary structure,and purchasing services. Handled by same employees, under thesame contract, or under different contractswhere both contracts are held by the mainprovider.
Provider Based Regulations Off-campus entities (Continued) Location Within a 35-mile radius of the campusof the main provider, except when Main provider has a DSH adjustmentgreater than 11.75%, and Is owned or operated by a governmental orquazi-governmental agency, or contractswith state or local government to operateclinics for low-income, non-Medicare orMedicaid patients
Provider Based Regulations Off-campus entities (Continued) Location Servesthe same patient population 75% of entity’s patients live in thesame ZIP codes as 75% of mainprovider’s patients, or 75% of entity’s patients who needservices offered by main provider aretreated by main provider, or If entity was not in operation for 12months, it is located in one of the ZIPcodes that makes up 75% of mainprovider’s business
Provider Based Regulations Off-campus entities (Continued) Location Must be located in the same State oradjacent States RHCs attached to hospitals with lessthan 50 beds are exempt from someof these location criteria
Seeking CMS Approval “A facility or organization is notentitled to be treated as providerbased simply because it or themain provider believe it isprovider-based.”
Seeking CMS Approval(Continued) The application for provider-based statusis called an “attestation” No time limit stated for CMS action If main provider bills as a provider-basedentity without approval, CMS can recoupany overpayments in all cost reportingyears subject to reopening Approval is good until there is a “materialchange”, such as a new managementagreement or relocation of the entity
Seeking CMS Approval(Continued) If considered provider-based on10/1/2000, it will continue to be providerbased through the hospital’s first costreporting period beginning on or afterJuly 1, 2003. “Considered” means: Written determination of provider-basedstatus from CMS, or Entity was billing and being paid as aprovider-based department or entity of thehospital
Seeking CMS Approval(Continued) If located on main provider’scampus, Submitfacility:an attestation stating that the Meets applicable provider-based criteriaand Will fulfill the obligations of hospitaloutpatient departments and hospitalbased entities. Must maintain documentationsupporting the attestation and makethat documentation available to CMSand FI upon request.
Seeking CMS Approval(Continued) If located on main provider’scampus, Approvalis granted effective thedate the entity is licensed, staffed,and equipped to treat patients CMS says they won’t recoupoverpayments if they later determinerequirements were not met However, CMS could say that the mainprovider filed a false attestation andrecoup the overpayments!!!
Seeking CMS Approval(Continued) If located off campus, Submitan attestation stating that thefacility: Meets applicable provider-basedcriteria, and Will fulfill the obligations of hospitaloutpatient departments and hospitalbased entities. Mustsubmit supportingdocumentation along with attestation
Seeking CMS Approval(Continued) Exception for “Good Faith Effort” CMSwon’t recoup overpayments forprovider-based entities if: Entity met all applicable requirements Main provider billed for services as ifthe entity were provider based Correct site of service indicators wereused on CMS-1500
Other Provider-BasedIssues EMTALA Bill with correct site of servicecode 22for provider-based clinic 11for freestanding clinic
Other Provider-BasedIssues Sharing space with other departments orentities DRG window applies (Not for CAH) Must meet life safety code requirements Could be expensive JCAHO Ancillary Services Lab
Other Provider-BasedIssues 1,500 cap for O/P therapies willnot apply to hospital O/Pdepartments Ifhospital has a freestanding PT, OTor ST office, consider converting toprovider-based before the 1,500limit takes effect
Other Provider-BasedIssues At off-campus locations, must give patienta notice of their coinsurance beforetreatment“If the exact type and extent of care needed isnot known, the hospital may furnish a writtennotice to the patient that explains that thebeneficiary will incur a coinsurance liability tothe hospital that he or she would not incur ifthe facility were not provider-based.” “The hospital may furnish an estimate basedon typical or average charges for visits to thefacility, while stating that the patient’s actualliability will depend upon the actual services
Other Provider-BasedIssues Joint ventures Allowable,if the entity: Is partially owned by at least oneprovider, and Is located on the campus of a providerthat is one of the owners, and Be provider-based to the provider onwhose campus the entity is located
Other Provider-Based Issues Management ContractsContract must be held by main provider, not aparent or sister Contract must state: Provider has control Contractor staff are subject to hospital policiesand procedures Contractor’s policies must be approved byprovider Requirement for periodic written reporting If for an off-campus site, the provider’s controlmust be clear and the provider must employall employees who furnish direct patient care
ClinicsRural Health Clinics:Conditions of Participation& Operations/Billing Issues
Rural Health ClinicsSee Regulations at 42 CFR §491 Must be located in a rural area Not“urbanized” in the mostrecent census Includes portions of extendedcities determined to be rural bythe Census Bureau RHC can be provider-based orfreestanding; mobile or
Rural Health Clinics Must be located in a “shortagearea” MedicallyUnderserved Area (MUA) HealthProfessional Shortage Area(HPSA) Containsa population group with ahealth professional shortage Designatedby the State (andcertified by Medicare) as an areawith a shortage of personal health
Rural Health Clinics MUAs are being redefined Somemay be eliminated If your RHC qualified becauseit's in an MUA, pay closeattention to the final rule, whenit’s published http://www.bphc.hrsa.gov/databases/newmua/ HPSAs are continuallyupdated http://bhpr.hrsa.gov/shortage/
Rural Health Clinics What if you lose your shortagearea? CMSnotifies provider Submit an application to updatemedically underserveddesignation within 120 days.Can continue as RHC for 120days. HRSA reviews application
Rural Health Clinics Exception process An existing RHC may apply for anexception from disqualification Submit written request to CMS regionaloffice within 180 days from the date CMSnotifies the RHC that it is no longerlocated in a shortage areaCMS RO may grant a 3-yearexception Can renew essential provider statusby submitting written assurances tothe CMS regional office that theycontinue to meet the conditions
Rural Health Clinics Exception process Terminationof RHC status iseffective the last day of the 6thmonth from the date CMSnotifies the clinic of a finaldetermination of ineligibility(including denial of anyexception request submitted).
Rural Health Clinics Staffing Mustinclude one or more physicians,and one or more physician'sassistants or nurse practitioners Physicians and mid-level practitionersmay be owners, employees orcontractors of the RHC Mayinclude ancillary staff who aresupervised by the professional staff Mid-level practitioner must beavailable to furnish patient care atleast 50 percent of the RHC hours
Rural Health Clinics Staffing Physicianresponsibilities Medical direction, consultation andmedical supervision of health care staff Helps develop, execute, andperiodically review written policies Reviews patient records, providesmedical orders, and provides servicesto patients Provides medical direction at least onceevery 2 weeks, and is available forconsultation, assistance with medicalemergencies, or patient referral. (c) Physician assistant and nurse
Rural Health Clinics Staffing Mid-LevelPractitioner responsibilities Helps develop, execute, and reviewwritten policies Assists with physician’s periodic reviewof patients' records Provides patient care services (notperformed by a physician): Provides services in accordance with theclinic's policies Arranges for, or refers patients to, neededservices that cannot be provided at the clinic;and Assures that adequate patient health recordsare maintained and transferred as required
Rural Health Clinics Staffing Temporarystaffing waiver If the RHC has been unable to hire midlevel practitioners to be on site 50% ofRHC hours, despite reasonable effortsin the previous 90-day period Waiver is good for 1 year, then CMS willterminate RHC from Medicare program Can re-apply for waiver, but no earlierthan 6 months after the expiration of theprevious waiver
Rural Health Clinics RHC Services Servicesand supplies commonlyfurnished in a physician's office,clinic or ER Basic lab services: Urine Hemoglobin/hematocrit Blood sugar Examination of stoolspecimens for occultblood; Pregnancy tests; and Primary culturing for transmittalto a certified laboratory.
Rural Health Clinics Agreements and Arrangements RHChas agreements orarrangements to provide: Inpatient hospital care Physician services (regardless wherefurnished); and Diagnostic and laboratory services notavailable at the RHC Ifthe agreements are not in writing,there is evidence that patientsreferred by the clinic or center arebeing accepted and treated
Rural Health Clinics Quality Assessment andPerformance Improvement Mustdevelop, implement, evaluate,and maintain an effective, ongoing,data-driven QAPI program Must be appropriate for thecomplexity of the RHC's business,and focus on maximizing outcomesby improving patient safety, qualityof care, and patient satisfaction
Rural Health Clinics RHC Reimbursement FreestandingRHCs and ProviderBased RHCs at Hospitals with 50 orMore Beds Cost based, subject to an "allinclusive rate" per visit Encounter with more than one healthprofessional 1 visit Multiple encounters with the samehealth professional on the same dayand location 1 visit, unless the patientsuffers an illness or injury requiringadditional diagnosis or treatment after
Rural Health ClinicAll-Inclusive RatesCalendar 2001Calendar 20021/1/03 - 2/28/033/1/03 - 12/31/03Calendar 2004Calendar 2005 63.1464.7866.4666.7268.6570.78
Rural Health Clinics RHC Reimbursement Provider-BasedRHCs at Hospitalswith Less Than 50 Beds Cost based, not subject to “allinclusive rate”
Rural Health Clinics RHC Reimbursable CostsCMS Pub. 100-04, Ch. 9, §40 Compensation for physicians (includingsupervising physicians), mid-levelpractitioners, clinical psychologists, andclinical social workers Cost of services and supplies incident toservices provided by these healthprofessionalsCosts of physician services furnishedunder contract arrangements RCE Limits doe not apply to physiciancosts
Rural Health Clinics RHC Reimbursable CostsCMS Pub. 100-04, Ch. 9, §40 Overheadcosts, includingadministration, use andmaintenance of the facility, anddepreciation costs; Cost of visiting nurse services andrelated supplies, if the RHC islocated in an area with a shortageof HHA services
Rural Health Clinics RHC Non-Reimbursable CostsCMS Pub 100-04, Ch. 9, §40.1 Itemsand services not coveredunder Medicare Dental services, eyeglasses, routineexaminations Itemsand services not included inthe definition of RHC services Independent laboratory services,durable medical equipment, andambulance services
Rural Health Clinics RHC Non-Reimbursable CostsCMS Pub 100-04, Ch. 9, §40.1 Costof covered items andservices not considered RHCservices Some items and services coveredunder Part B are not considered RHCservices even when furnished by anRHC Durable medical equipment,ambulance services, outside therapyproviders, prosthetic devices, etc.
Rural Health Clinics Medicare Bad Debts RHCsand FQHCs may claimreimbursement for Medicare baddebts Must follow all rules in 42 CFR§413.80. For FQHCs, bad debts are limited toMedicare coinsurance amountsbecause no deductible is applied toFQHC services FQHC cannot claim waivedcoinsurance as a Medicare bad debt
Rural Health Clinics Productivity levels Physicians:4,200 visits per FTE Mid-Level Practitioners: 2,100 visitsper FTE If productivity levels are not met,RHC cost per visit is reduced FI may grant exceptions toproductivity levels
Rural Health ClinicBilling All charges are billed on UB-92 Willshow up on the PS&R Summary Professional fees are not billedseparately on the CMS-1500 Physician costs are part of Medicarereimbursable cost, so the relatedcharge must remain
Rural Health ClinicIssues Ancillary services at providerbased RHCs should be billed ashospital ancillary Not all State Medicaid plans coverRHC services, or may not payreasonable rates Besure to check first!
Rural Health ClinicStrategies RHCs at hospitals with 50 beds often lose money Cost per visit is greater than the limitCondsider converting the RHCto a: Provider-basedclinic Federally Qualified Health Center
Federally Qualified Health Center(FQHC) FQHC Qualifying Criteria Furnishservices to a medicallyunderserved population, or Be located in a medicallyunderserved area Receives (or is eligible to receive)grant funding under the PublicHealth Service Act: Migrant health center (§329) Community health center (§330) Homeless health care center (§340)
Federally Qualified Health Center(FQHC) Governing Board –FQHC boards must have 9 - 25 members A majority of “consumer members” Receive the majority of their health care at theFQHC Non-consumer members should be fromprofessional fields such as legal, financial, healthcare, and social services No more than 50% of the non-consumermembers can earn more than 10% of theirincome from health care Employees and relatives of employees areineligible
Federally Qualified Health Center(FQHC) Governing Board – Mustmeet at least once a month Establishes general policies,approves the center's annual budget,approves the selection of FQHCdirector Must carry legal and fiduciaryresponsibility for clinic operations andgrants Must perform periodic strategicplanning and evaluate progress
Federally Qualified Health Center(FQHC) Governing Board – Musthave full authority over allaspects of clinic operations No other entity/individual can overrideor veto governing board decisions Must meet at least once a month
Federally Qualified Health Center(FQHC) FQHC Services Similarto RHC, but includes certainpreventive care services: Medical social services Nutritional assessment and referral Preventive health education Children's eye and ear examinations Prenatal and post-partum care Prenatal services
Federally Qualified Health Center(FQHC) FQHC Reimbursement Medicarelimitsis cost-based, subject to Different limits for urban & rural Limits are higher for FQHC than for RHC 50 bed limit does not apply to FQHCs MedicarePart B deductible does notapply for FQHC services Medicaid cost-based programs werephased out
FQHC LimitsCalendar 2001Calendar 20021/1/03 - 2/28/033/1/03 - 12/31/03Calendar 2004Calendar 2005Urban 98.03 100.57 103.18 103.58 106.58 109.88Rural 84.28 86.47 88.71 89.06 91.64 94.48
ClinicsProvider BasedFinancial Analysis
Provider-Based ClinicStudies For PPS Hospitals: Calculatedifference in RBRVSreimbursement Based on site-of-service code CalculateAPC reimbursement Based on CPT code
Provider-Based ClinicsReimbursement ImpactExample: Primary care clinic in a PPS Hospital(6,500 Medicare visits)PhysicianChange in RBRVS Fee Schedule PmtsOutpatient PPS (APC) ReimbursementNet Medicare ImpactHospital (100,066) 304,328 204,262
Provider-Based Clinic Studies For Critical Access Hospitals: Calculatedifference in RBRVSreimbursement Prepare pro-forma cost report toestimate cost-based reimbursement The tricky part: Allocation of OverheadCosts To be conservative, consider allocatingonly A&G costs at first, then includeother allocations using estimatedstatistics Provide a range for reimbursement
Provider-Based ClinicsReimbursement ImpactExample: Primary care clinic in aCritical Access Hospital (5,300 Medicare visits)PhysicianChange in RBRVS Fee Schedule PmtsMedicare Cost Report ReimbursementNet Medicare ImpactHospital (46,274) 217,766 171,492
Provider-Based ClinicStudies For all Hospitals: ObtainMedicare volumes by CPTcode for the clinics. Can using an overall payer mix, but theresults are not as reliable If that’s all you can get, include clear andappropriate disclaimers and caveats Makesure to include ancillaryservices in the appropriate hospital
ClinicsIssues Specific toCritical Access Hospitals
Clinics in CAHs Rural Health Clinics 101%of cost for RHC services Not because you’re CAH, but becauseyou’re less than 50 beds Cost includes professional services Remember: All Medicare RHC chargesare billed on the UB-92 – no split-billing! Productivitylimits still apply
Clinics in CAHs Provider-Based Clinics 101%of cost for technical (or “facility”)charges Cost excludes professional services Clinic visit charges billed on UB-92 Potentially a significant increase inreimbursement Howmuch of a benefit? Clinic payor mix vs. hospital payor mix Run the numbers
CAH Clinic Billing Method 1 “SplitBilling” Professional Fees billed on CMS-1500 Reimbursement RBRVS Fee Schedule Hospitalcharges (facility fee) billed onUB-92 Reimbursement Reasonable cost
CAH Clinic Billing Optional Method 2 “CombinedBilling” Bill outpatient services andprofessional fees on the UB-92 List outpatient on a separate line withappropriate revenue code, HCPCScodes, date of service and charge FL 42 Revenue codes 96X, 97Xor 98X Deductible & coinsurance apply
CAH Clinic Billing Optional Method 2 Medicarepays: 115% of RBRVS fee schedule forprofessional fees, and Reasonable cost for hospital charges
CAH Clinic Billing Optional Method 2 CAHmust have a copy of the form855R signed by the individualpractitioner The practitioner attests that he/she willnot bill the carrier for any servicesrendered at the CAH CAHis not required to have allphysicians/professional practitionersreassign their billing rights
CAH Clinic Billing Professional service performed bya non-physician NursePractitioner, PhysicianAssistant or Clinical Nurse Specialist Optional Method 2 FL 42 Revenue code 96X, 97X, 98X FL 44 HCPCS add modifier GF todesignate a non-physician
Clinics: Provider Based,Freestanding, andRural Health ClinicsSummary Table
Provider-Based Clinics vs.Freestanding asedClinicRHC Based on RBRVSschedule TechnicalComponentreimbursementbased on APCs(PPS hospitals) orcosts (CAH) Technical &Professional CostsPaid on Costs RBRVS paymentis consideredfinal settlement RBRVS paymentdecreased due toreduction inPractice RVU Some ProfessionalServices Paid FeeSchedule. Must“Carve Out” Costs
Provider-Based Clinics vs.Freestanding Clinics Clinic All services billedto Part B carrieron HCFA 1500 Two bills will begenerated: 1)HCFA 1500 forprofessionalservices, and 2)UB-92 fortechnical services Place of serviceon HCFA 1500 is“11” – office Place of serviceon HCFA 1500must be a “22” –outpatient hospital May combine bill“Non-Medicare”patientsRHC Medicare BillingUB-92. OtherCarriers Billed asFS Clinic Service.
Provider-Based Clinics vs.Freestanding Clinics nicRHCundlingervices Unbundling ofservice is NOTprohibited Unbundling ofservices ISprohibited Unbundlingprohibited. Allservices paid per visitrgecture NA Charges for thesame proceduremust be consistentbetween the hospitaland the clinic Charge per visit mustapproximate Cost pervisit Not reimbursable Deductibles andcoinsurance relatedto facility charge only Reimbursable viacost report alongwith all other Part Bbad debtsicare Baddicarets
Provider-Based Clinics vs.Freestanding Clinics nicRHCnsurance Coinsuranceequals 20% ofthe professionalservices amount 20% of hospitaltechnical charge 20% of RHC clinicchargerheadcation Allocatedhospital O/H isnot reimbursable Allocation of hospitalO/H is included inallowable costs forclinic Overhead costallowable on RHCCost Report No additionalreimbursementfor providercomponent time Provider componentonly portion of salaryis included inallowable cost forclinicRCE limits do notapply PhysiciansCompensationallowableSubject to productivitylimitsReasonableness TestCarve outs for Prof.Billingssicianmpensation
Provider-Based Clinics vs.Freestanding Clinics nicRHCCcedures Only thosesurgeries listedon the ASC listwill be covered Ambulatorysurgeries will becovered regardlessof whether or not thesurgery is on theASC list Why?ificationtification Meet criteria forphysician cliniconly Clinic must meet thesame licensure andcertificationstandards as theHospital Separate COP
Requirements for all provider-based entities (Continued): Integrated clinical services Medical staff has privileges at main provider Clinical oversight is the same as for all other clinical departments of main provider Medical records "integrated into a unified retrieval system (or cross-reference) of the main provider."
