Rural Health Clinic: Topics in Billing, Cost Reporting & Reimbursement

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1 Rural Health Clinic: Topics in Billing, Cost Reporting & Reimbursement Date or subtitle November 1, Discussion Overview RHC Billing Resources CMS Charts; CMS Manuals Billing for Pneumococcal, and Influenza (including H1N1) Vaccines 2010 RHC Maximum Rates; Fee Schedule Payment Changes Requesting Medicare Provider Statistical & Reimbursement Reports RHC Billing/Reimbursement; Common Questions Wisconsin Medicaid Quarterly Reports/Annual Filing Medicare Bad Debts 2 Title goes here 1

2 Medicare Billing Information Chart for Rural Providers Download at on CMS website at: Title goes here 2

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4 7 Resources CMS Web site 8 Title goes here 4

5 Resources CMS Web site Sample excerpt, CMS Online Manual (Claims Processing): Rural Health Clinics (Rev. 1, ) PM A-99-8, Rev. 810, CR 1133, PM A Rural Health Clinics (RHCs) must furnish the following laboratory services to be approved as an RHC. However, these and other laboratory services that may be furnished are not included in the encounter rate and must be billed separately: Chemical examinations of urine by stick or tablet method or both; Hemoglobin or hematocrit; Blood sugar; Examination of stool specimens for occult blood; Pregnancy tests; and Primary culturing for transmittal to a certified laboratory (No CPT code available). Effective January 1, 2001, freestanding RHCs/Federally Qualified Health Centers (FQHCs) bill all laboratory services to the carrier, and provider based RHCs/FQHCS bill all laboratory tests to the FI under the host provider s bill type. In either case payment is made under the fee schedule. HCPCS codes are required for laboratory services. (See 40.4 for details on RHC billing.) 9 Billing for Pneumococcal, and Influenza (including H1N1) Vaccines Pneumococcal and flu (including H1N1) vaccines have special treatment for cost-based reimbursement. Do not file claims for flu/ppv. Requires maintaining a log with the patient s name, HIC number, and date of service. Hint: Automate! Reported and paid separately on the RHC cost report Title goes here 5

6 Billing for Pneumococcal, and Influenza (including H1N1) Vaccines Computation of Flu/PPV Costs Data Required: Estimated time to give injection (usually 8-12 minutes) Total injections Medicare injections Direct supply costs (H1N1 combined with flu) Total health care staff hours Compute ratio of injection time to total health care time Medicare RHC Maximum Payment Rates RHC Reimbursement Limits * Maximum $ $ $ $ $ $ $ Increase 2.9% 3.1% 2.8% 2.8% 1.8% 1.6% 1.2% *Limits do not apply to RHCs in hospitals < 50 beds Title goes here 6

7 2010 Medicare/Medicaid Fee Schedule Amounts Non-RHC Fee Schedule Amounts WI Medicare WI Medicare WI Medicare WI Medicaid Projected Projected /01/ (23% reduction) (6% reduction) Office/outpatient visit, new $ 36 $ 22 $ 28 $ Office/outpatient visit, new $ 63 $ 37 $ 49 $ Office/outpatient visit, new $ 92 $ 55 $ 71 $ Office/outpatient visit, new $ 143 $ 79 $ 110 $ Office/outpatient visit, new $ 179 $ 101 $ 138 $ Office/outpatient visit, est $ 18 $ 12 $ 14 $ Office/outpatient visit, est $ 36 $ 22 $ 28 $ Office/outpatient visit, est $ 62 $ 30 $ 48 $ Office/outpatient visit, est $ 93 $ 48 $ 72 $ Office/outpatient visit, est $ 125 $ 70 $ 96 $ Medicare Provider Statistical & Reimbursement Provider Statistical & Reimbursement (PS&R) report is an essential component of cost report reconciliation. This report summarizes all paid claims. It was previously mailed to providers. The PS&R Redesign System: Allows/requires users to download summary PS&R reports via the internet. All users must first establish an Individuals Authorized Access to CMS Computer Systems (IACS) account. Refer to MLN Matters MM6519 on the CMS website Title goes here 7

8 RHC Billing/Reimbursement RHCs are paid a flat rate for each face-to-face encounter based on the anticipated average cost for direct and supporting services (including allocated costs), with a reconciliation of costs (i.e., cost report) occurring at the end of the fiscal year. There are two types of RHCs; billing and payment are slightly different: 1.Independent RHCs bill RHC services to one of five regional fiscal intermediaries (transitioning to MAC). 2.Provider-based RHCs bill RHC services to the FI/MAC of the host provider (usually a hospital). RHC Billing/Reimbursement Common Questions: 1. Are nursing home visits RHC services? 2. What if the nursing home visits are performed outside of RHC hours of operation? 3. Are swing bed visits RHC services? Title goes here 8

9 2010 Medicare/Medicaid Fee Schedule Amounts Non-RHC Fee Schedule Amounts WI Medicare WI Medicare WI Medicare WI Medicaid Projected Projected /01/ (23% reduction) (6% reduction) Nursing facility care, init $ 81 $ 56 $ 62 $ Nursing facility care, init $ 113 $ 74 $ 87 $ Nursing facility care, init $ 145 $ 91 $ 112 $ Nursing fac care, subseq $ 39 $ 29 $ 30 $ Nursing fac care, subseq $ 60 $ 48 $ 46 $ Nursing fac care, subseq $ 79 $ 67 $ 61 $ Nursing fac care, subseq $ 117 $ 84 $ 90 $ Home visit, new patient $ 52 $ 24 $ 40 $ Home visit, new patient $ 75 $ 34 $ 58 $ Home visit, new patient $ 122 $ 47 $ 94 $ Home visit, new patient $ 162 $ 145 $ 125 $ Home visit, new patient $ 195 $ 180 $ 150 $ Home visit, est patient $ 51 $ 40 $ 39 $ Home visit, est patient $ 77 $ 64 $ 59 $ Home visit, est patient $ 113 $ 98 $ 87 $ Home visit, est patient $ 158 $ 145 $ 122 $ RHC Billing/Reimbursement Common Questions: 1. Can RHCs be paid for surgical services performed by RHC providers? 2. If so, how are surgery procedures paid when performed in the RHC? 3. What about surgical procedures performed in the hospital? 4. What about surgery follow-up visits in the RHC? Title goes here 9

10 RHC Billing/Reimbursement Common Questions: 1. Can a nurse provide an injection in the RHC when there is not a physician, PA, or NP present in the clinic? 2. Can a nurse injection be billed as an RHC encounter if a physician, PA, or NP is present in the clinic? Wisconsin Medicaid Quarterly Reports Quarterly Payments When a clinic has provided services as an RHC for 12 continuous months, it has the option of receiving quarterly payments by submitting a quarterly Medicaid Rural Health Clinic Quarterly Cost Report (referred to as "quarterly cost reports") in addition to the annual cost report. Wisconsin Medicaid's quarterly payments enable RHCs to increase cash flow throughout the year. Quarterly cost reports must be submitted within three months of the quarter's end Title goes here 10

11 Wisconsin Medicaid Quarterly Reports 21 Wisconsin Medicaid Cost Reports Report Submission The Medicaid annual cost report and supplemental documents are due 30 days after the Medicare cost report due date, as determined in the Medicare Rural Health Clinic and Federally Qualified Health Center Manual. A 30-day extension of the Wisconsin Medicaid due date may be granted if Wisconsin Medicaid receives a written request before the original due date expires. If an extension is requested, Wisconsin Medicaid provides a written response to the request. Failure to submit the annual cost report and supplemental documents within the specified timeframe will result in suspension of all cost settlement payments Title goes here 11

12 Medicare Bad Debts Medicare will reimburse the rural health clinic for all uncollectible Medicare deductibles and coinsurance, if considered to be allowable bad debts. The amount of allowable Medicare bad debts is added to the RHC cost report settlement Medicare Bad Debts Medicare bad debts are being disallowed if they are still being worked by a collection agency. Intermediaries are requesting a copy of the correspondence from the collection agency as to which claims have been returned to the provider as being noncollectible before they are allowing the bad debt to be claimed on the cost report Title goes here 12

13 Medicare Bad Debts CMS Pub. 15-I Section 308 states the criteria for allowable Medicare bad debts: 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 be actually uncollectible when claimed as worthless. Sound business judgment must have been established that there was no likelihood of recovery at any time in the future Medicare Bad Debts 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 Title goes here 13

14 Medicare Bad Debts Presumption of Non-collectibility, CMS Pub. 15-I Section 310.2: If after reasonable and customary attempts to collect a bill, the dept remains unpaid more than 120 days from the date the first bill is mailed to the beneficiary, the debt may be deemed uncollectible Medicare Bad Debts 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 Title goes here 14

15 Medicare Bad Debts 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) For More Information This presentation was prepared by: Jeff Bramschreiber, CPA Health Care Partner Wipfli LLP (920) Title goes here 15

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