NARHC Speaks at Senate Rural Health Press Conference

Pictured from left to right: Senator Tom Udall, Senator Martin Heinrich, NARHC President John Gill, Senator Al Franken, and Dr. Robert Rosenberg.

From left to right Senator Tom Udall, Senator Martin Heinrich, NARHC President John Gill, Senator Al Franken and Dr. Robert Rosenberg speak at a Senate Rural Health Press Conference.

WASHINGTON, D.C., May 23, 2017–The National Association of Rural Health Clinics (NARHC) was invited to speak at a Senate press conference on rural health hosted by Senator Martin Heinrich (D-NM). NARHC President John Gill stressed the important role Medicaid plays in allowing RHCs to provide care in rural communities. John emphasized that the average RHC sees a much greater percentage of Medicaid patients than the average fee-for-service clinic and therefore RHCs are particularly concerned about any potential cuts or changes to the Medicaid program that could reduce Medicaid payments to RHCs. Senator Martin Heinrich (D-NM) opened the press conference and was followed by Senator Bob Casey (D-PA), Senator Tom Udall (D-NM), and Senator Al Franken (D-MN) who all made comments on health care reform and its impact on rural health.

Views – 7

Updates from Cahaba on RHC Claims

Nov. 29, 2016

ALL RHC Medicare claims – whether “single line” or “multi-line” MUST have the CG modifier on the “pay” line. If a single line, the CG modifier goes on the single line with the HCPCS code for that RHC visit.

If multi-line, then the CG modifier goes on the line (typically the line that is the principle reason for the visit) on which you have rolled up all of the charges for the encounter.  This lets CMS know that this is the line on which they should base the beneficiary co-insurance.

If you had claims rejected because the claim did not have the CG modifier, then you will need to re-file the claim.  Here is a link to the instructions for re-filing a Cahaba claim:

Bill Finerfrock

Views – 154

CG Modifier & Cahaba

Nov. 23, 2016

As many of us know, beginning October 1, most RHC Medicare claims (with a few exceptions) were required to have modifier CG on the claim. While we (the NARHC) communicate billing updates through this listserv as soon as we learn about them, this is ultimately a responsibility of each MAC to communicate these updates to their jurisdiction.

NARHC staff has discovered that Cahaba did a very poor job of communicating the Oct. 1 CG changes to their providers. A significant number of RHCs in Cahaba’s jurisdiction were completely unaware of the CG modifier changes. Making matters worse, Cahaba’s customer service department was also not aware of these billing changes, even though their IT department had updated their system per the Oct. 1 guidelines.

As a result, RHCs that were oblivious to the CG modifier changes started calling Cahaba and inquiring why their claims were being denied. Unable to accurately diagnose the problem (that there was no CG modifier on the claims), Cahaba’s customer service department began telling people that it was a “system” problem on Cahaba’s end and that they were working on a fix.

NARHC staff has confirmed with CMS central staff that this is not a problem with the FISS or some other Cahaba system, but rather a severe lack of communication within Cahaba, and to Cahaba providers, around the CG modifier changes.

The good news is that CMS and Cahaba realize the true nature of the problem now, and we have been told that Cahaba is actively working on getting all their departments on the same page here. We have made it clear that Cahaba needs to detail specific instructions on how RHCs should refile the claims that were rejected for not following the CG rules. We anticipate that Cahaba will issue a correction soon that explains their oversight and properly educates their RHC providers on the CG changes.

Nathan Baugh
NARHC Director of Government Affairs
(202) 544-1880

Views – 186

Election “First Take” Analysis

November 10, 2016

The following is our quick analysis of the election for your reading pleasure. NARHC will also be creating a more RHC-centric analysis and sending that out sometime next week via List Serve.

Two days ago, Republican candidate Donald Trump was elected as the 45th President of the United States. Trump defeated his Democratic opponent, Hillary Clinton, despite an overwhelming sense by almost everyone going into Election Day that Clinton would win.

Trump’s 276 electoral votes, which is only six more than are required to win the election, does not speak for the decisiveness of his victory. Those who paid close attention to polling data and projections on reputable websites, such as 538 and Real Clear Politics, expected a very close race with Clinton edging out a win. Not only did Trump outperform projections in most of the up for grab “swing” states such as Pennsylvania, North Carolina and Florida, he was also able to win several states that historically vote Democrat that he was not expected to have a chance of winning. The most notable of these states include Wisconsin and Michigan.

Most pundits and pollsters dismissed the possibility of a “Trump effect” in which Trump outperformed polls due to the people being surveyed not wanting to go on record that they were supporting Trump. The Trump effect played a significant role in the primary elections. Trump had also narrowed a lead that Clinton held over the past two weeks. In fact, Trump was polling within the margin of error in many of the states he won.

This was, by any measure, a transformational election. It was an “insiders” vs. “outsiders” election more than a “liberals” v. “conservative” election at the Presidential level. It was also an economic election. Places like Pennsylvania, Ohio, Wisconsin and Michigan voted red. While the national economic numbers are improving, general confidence in the economy has yet to make a full recovery after the great recession. Many Americans felt that they have been passed over. This was middle class America’s “I will not be ignored” moment.

Looking down the ticket, the House of Representatives will remain in Republican control. This was always expected. The Senate will also remain in Republican control despite a much less certain outlook going into Election Day. However, Republicans will not have a “super majority” of 60 seats needed to override a Senate filibuster. The results of the House and Senate elections will be covered in greater detail later in this document.

But now the work begins.

It is worth noting that this will be the first time the GOP has controlled the House, Senate and White House since 1928 so this is something none of us have ever experienced. The Republicans will also now be able to nominate a ninth Supreme Court Justice, which could swing the political balance of the court towards conservative ideology.

The GOP victories down ticket (House and Senate) suggest that there are opportunities to get things done in the legislative arena that may not have been possible under divided government. We still have the filibuster in the Senate but it is possible that we will see, particularly in the first 100 days, legislation enacted that makes some significant changes in policy. The GOP had the odds against them relative to the number of seats they were defending relative to the Democrats. But those tables are turned in 2018 when more than 20 Democratic Senate seats will be up and only a handful of GOP seats. Trump is a negotiator, not an ideologue, so he will likely be open to deals that wouldn’t be possible under a more ideologically driven politician. Democrats up for re-election in 2018 may be inclined to “work with” the new President, particularly if they are in a “red” state.

With regards to health policy, this may result in some down-the-road changes to MACRA but the core will remain. MACRA enjoyed strong bi-partisan support and will likely continue to enjoy bi-partisan support. However, changes could be made that might have been unrealistic just a few weeks ago.

Additionally, key provisions of the Affordable Care Act (ACA) are in jeopardy (individual mandate, employer mandate). It may also accelerate Health Plan departure from the ACA Exchanges because they want more in the way of protections from risk and those are not likely to occur under a GOP Congress. Lack of a filibuster-proof Senate means a full repeal of the ACA is unlikely but dramatic changes will likely occur.

Trump and the GOP Congress can, despite the filibuster, use Budget Reconciliation – the same legislative process President Obama used to pass some of the key provisions of the ACA – to repeal and or replace key provisions of the ACA with only a simple majority. Some provisions of the ACA, such as protections for patients with preexisting conditions and allowing consumers to remain on their parent’s insurance plan until they are 26, remain popular and could exist in some form under a Republican alternative.

Reconciliation could also be the likely process for enacting a tax reform package and possibly other policies. Under reconciliation Congress can pass any legislation dealing with the raising or spending of money via the tax code or entitlement with a simple majority; a reconciliation bill cannot be filibustered. Expect to hear more about “reconciliation” as the principle vehicle for change.

In general, all of the policies that President Obama enacted via Executive Order because he could not pass those policies with legislative success, will likely be rescinded by President Trump. Also, the precedent that President Obama set in using Executive Orders may be employed by President Trump. The use of Executive Orders by President Obama was always a double-edged sword because it sets a precedent for his successors to do the same thing.

The Trump Administration is also expected to put a “hold” on any regulatory actions currently pending, either in development or in the proposed rule phase. Regulations that have been finalized cannot be unilaterally rescinded but the Trump Administration could (again following President Obama’s lead) announce that they will not enforce some of the policies adopted in recently finalized rules with which they may disagree.

This likely means to the end of several other Obama health care initiatives such as the Health Care Payment Learning and Action Network. This was a creation of the Obama Administration and, if for that reason alone, will likely be disbanded by the Trump Administration. Republicans have grown increasing critical of the alternative payment models (APM) that have come out of another ACA creation, the Centers for Medicare and Medicaid Innovation (CMMI) within CMS. The Trump Administration could significantly scale back CMMI or perhaps eliminate it altogether. Had Clinton been elected, many of Obama’s initiatives would have likely been continued. Further, it would not have been surprising if Clinton retained many of the Obama appointees at CMS/HHS. With Trump’s victory, it will be a whole new cast of characters in HHS and every other Agency.

Finally, the transition from Obama to Trump begins today. President Obama and Trump are scheduled to meet in the coming days to discuss the transition process. Engaging with the Trump transition team will be incredibly important. The transition team will be meeting with the current political and career people in every agency, including HHS and CMS. They will be getting briefing books on every policy in development and we will want to get in their ear to make them aware of our concerns on various topics. The transition team will also help decide who Trump appoints to take over these Agencies. His appointees will be a likely indication of the policies that the Trump Administration Agencies will act on.


House and Senate Analysis:

Going into last night’s election, Republicans held a four-seat majority in the Senate and a 54-seat majority in the House of Representatives. Final polls before the election showed Senate control likely to be a very close race. Many believed the result would be a 50-50 split in the Senate or a one vote majority either way. Republicans won 20 of the 33 Senate elections, ending the night with at least a 51-seat majority going into 2017.

Some of the Senate races still have not been decided. Louisiana’s Senate race, with a field of 24 candidates, ended with no candidate earning the 50 percent threshold needed to win. A runoff election will be held December 10 to decide that election. New Hampshire’s race, which ended with Maggie Hassan and Kelly Ayotte only 700 votes apart, will require a recount.

Polling leading up to the election indicated that Democrats were expected to make significant gains in the House of Representatives. Two of Louisiana’s congressional races will result in a runoff election, however, Republicans will control at least 240 of the 247 seats that they held in the 114th Congress. Polling did not forecast Democrats to reclaim the majority at any point in this election cycle, but this result is far short of predictions.

Congress will still have a major role to play in the policy making process. Rep. Paul Ryan of Wisconsin has announced he will seek a new term as Speaker of the House of Representatives. It is unclear if he will be challenged for the Speakership by another member of the Republican Conference. Senator Mitch McConnell of Kentucky is likely to remain the Senate Majority Leader. Earlier this year, Speaker Ryan outlined his platform on a number of foreign and domestic policy areas called “A Better Way.” A Better Way is available online. This website offers a glimpse into the policy agenda the Republican-controlled Congress might pursue.

A list of the Senate results can be viewed online as well as the results of the House of Representatives elections.

Bill Finerfrock, Matt Reiter, and Nathan Baugh
(202) 544-1880

Views – 199

RHC Guide to the MACRA Final Rule

October 28, 2016

We understand that there are a lot of questions and interest around MACRA (Medicare Access and CHIP Reauthorization Act) especially around the specifics of how it does and does not affect RHCs. We have put together the following Q&A to address many of the relevant aspects of the final rule for RHCs.

It is important that we make a distinction at the outset between RHC claims – those submitted for RHC services using a UB-04 claim form and traditional Medicare Part B claims submitted by Physicians, PAs and NPs using an individual or group NPI using a 1500 claim form.

Q: Will my RHC All-Inclusive Rate be affected by the new Medicare Incentive Payment system (MIPS)?

A: No. The final rule states that because RHC services furnished by eligible clinicians (Physician, PAs and NPs) are not reimbursed under the Medicare PFS (Physician Fee Schedule), RHC services are not covered by the MIPS program. Reimbursement for RHC UB-04 claims will be unaffected by this new program. The RHC Cap will continue to adjust each year to reflect medical inflation and productivity improvements.

However, non-RHC claims submitted by RHC Physicians, PAs and NPs to Medicare Part B (i.e. items billed on a 1500-form) may be affected (see below).

Q: Will non-RHC services (billed on a 1500) using the individual/group NPI be affected by MACRA?

A: Potentially. We believe MOST RHC physicians, PAs and NPs will fall under a low-volume exemption threshold (see below), which will exempt these clinicians and their 1500 claims from MIPS reporting and payment adjustments.

Q: What is the low-volume threshold?

A: CMS has determined that Physicians, PAs and NPs who do not submit sufficient Medicare Physician Fee Schedule (1500) claims will be exempt from the MIPS program. These are classified as “low-volume” providers. A low-volume provider is defined as a Physician, PA or NP who, during the low-volume threshold period,

  1. Has billed Medicare Part B allowed charges of $30,000 or less during the billing cycle; OR
  2. Provided care to 100 or fewer Medicare Part B-enrolled beneficiaries during the billing cycle.

RHC claims are NOT counted when determining whether or not a clinician meets the threshold.

  1. What billing cycle will CMS use to do the claim or patient count?

CMS will review Physician, PA and NP Medicare Physician Fee Schedule billing for the 24 months preceding the reporting year broken into two, separate 12 month calculations or “billing years”. These will not be calendar years but rather so-called “billing year”. For 2017 (2019 payment adjustment year), the “billing year” reviewed by Medicare will be claims submitted between September 1, 2015 through August 31, 2016. CMS will conduct a second “billing year” calculation based on claims submitted between September 1, 2016 through August 31, 2017 to determine additional eligible clinicians and groups.

If the individual Physician, PA or NP claim submissions are $30,000 or less during EITHER of these billing years, the clinician will be considered exempt from MIPS for the associated Payment Adjustment Year. Each year after 2017, CMS will conduct a similar review with the older year dropping from the calculation and the most recent September – August “billing year” being added to the calculation. Again, as long as the Physician, PA or NP meet the low volume criteria during either of the two years, the clinician would be deemed MIPS exempt.

CMS will also use this same 24 month review method to do the patient count.

Q: How will Medicare know if an individual clinician provides care to fewer than 100 Part B-enrolled Medicare beneficiaries?

A: CMS will use social security numbers reported on 1500 claims to determine this part of the exclusion. This is a count of patients, not claims. For example, if an eligible clinician provides multiple services to one RHC beneficiary over the course of the “billing year”, this only counts as one Medicare enrolled beneficiary for purposes of the low-volume threshold.

Q: Will Clinicians have to apply for the low-volume exemption?

A: No. CMS says it set up the low-volume threshold determination period in such a way that will allow CMS to notify Physicians, PAs and NPs who qualify for the exemption during the month of December preceding the quality reporting year. CMS has not specified how notification will occur. We expect that CMS will issue guidance on this within the next few weeks.

Q: How is CMS identifying individuals versus groups for the purposes of the low-volume exclusion?

A: For individuals, the low volume threshold exclusion is determined by the Tax ID Number (TIN)/National Provider Identifier (NPI) combination. For groups, low volume exclusions are determined by simply the TIN. Individual eligible clinicians that are part of a group that chooses to report as a group, will be required to participate in MIPS if the entire group qualifies.

For example, if five RHC eligible clinicians are a part of the same group (TIN) and each eligible clinician bills $10,000 of allowable Medicare Part B charges, then that group has the option to report as a group and be subject to MIPS as a group (meaning they all get one group quality score) or to report as individual eligible clinicians and take the low-volume exemption.

In this example, if they report as a group with total Medicare allowable charges of $50,000, then their Part B claims are going to be required to report MIPS quality data to CMS and have their Part B (1500) claims subject to MIPS adjustments (positive or negative). However, if the clinicians report individually, $10,000 per, then all five would be exempt from quality reporting and exempt from MIPS adjustments (positive or negative) on their Medicare Part B claims.

Q: If an eligible clinician qualifies for the low-volume exclusion, can they chose to opt-in to MIPS and receive an adjustment?

A: No. Once it has been determined that for the reporting year a clinician or group is deemed “low-volume”, the clinician or group is ineligible to participate in MIPS for that reporting year.

Q: Can Rural Health Clinics voluntarily report MIPS data?

A: Yes RHCs may voluntarily report MIPS data and receive a MIPS CPS score. However, any MIPS data reported on RHC services would not be used for the purposes of the MIPS payment adjustment on non-RHC claims.

At some point Congress may propose to extend the MIPS program to RHCs and it would be helpful to know how RHCs would fair under the MIPS data reporting requirements.

Views – 266

CG Modifier


CMS has produced an FAQ document that addresses many of the questions/scenarios relative to the use of the CG modifier that have been raised on this listserve.
I strongly encourage you to review this document.

As will see when you review the document, there is an FAQ that addresses one of the scenarios you posed by Lori Donals:

Q. If a medical service and a preventive service are furnished on the same day, should modifier CG be reported with both services?

A. No. Modifier CG should be reported only with the medical service HCPCS code that represents the primary reason for the medically necessary face-to-face visit when medical and preventive services are furnished on the same day.
To your specific examples.

Scenario One: It should be the line (CPT code) that was the primary medical reason for the visit. So if in the scenario you are using, the primary medical reason the patient came into the RHC was for skin lesion removal (CPT 17000) and you also performed the introductory to Medicare physical (G0402). The CG modifier goes on the line where you report the 17000.

In this specific situation, you would get two AIR payments. One for the medically necessary visit (17000) and one for the IPPE (G0402). The coinsurance would be applied to the lesion removal (medically necessary visit) and there would be no coinsurance for the IPPE (it’s waived for this service).

Scenario two: Again, the CG modifier goes on the line that is the primary reason the patient came into the RHC for a visit. Because both are preventive visits, there is no “medical” or “mental health” visit. So here, you get to choose. Did the patient come in for the IPPE (G0402) or the Well Woman exam (G0101) and you combined them into the same visit? Either way, you pick one that is “primary” and you put the CG modifier on that line.

Typically, only one line of the claim requires the CG modifier. The principle exception to this is if you provide BOTH a Medicare covered medical visit and a Medicare covered mental health visit to the same patient during the same visit, then both lines would have the CG modifier. This is typically going to be the only time you’d have the CG modifier on the claim more than one.

Hope this helps.

Bill Finerfrock

Views – 282

HCPCS Reporting Changes

Oct. 1, 2016

Hopefully everyone is aware of the HCPCS reporting changes set to kick in next week. The best place to review those changes is here:

We also wanted to clarify a few things regarding these changes.

  1. The CG modifier should be used even when the only service listed on the UB-04 claim is a preventive service.
  2.  HCPCS codes G0436 and G0437 will be discontinued effective for dates of service after 10/1/2016. The proper codes for tobacco cessation counseling are 99406 and 99407.
  3. For purposes of RHC billing, modifiers 25 and 59 are interchangeable. We have confirmed this with CMS.

Nathan Baugh
National Association of Rural Health Clinics

Views – 259

2018 Essential Community Provider list & petition

Sept. 1, 2016

Under the Affordable Care Act (ACA), Qualified Health Plans (QHPs), are required to include essential community providers (ECPs) that serve predominantly low-income, medically-underserved individuals in their networks

Rural Health Clinics are eligible for designation as ECPs

As part of the Plan Approval process, the Secretary Health and Human Services (HHS) has established criteria mandating inclusion of a sufficient number and geographic distribution of ECPs in an issuer’s network to ensure reasonable and timely access to a broad range of such providers for low-income, medically-underserved individuals in their service areas.

To demonstrate satisfaction of the ECP requirement, Qualified Health Plans must submit a list of ECP’s in the Plan’s network with whom the Plan has contracted to provide health care services to low-income, m edically-underserved individuals in their service areas.  Failure to meet the ECP criteria would be grounds for rejection of the Plan’s application.

The Department of Health and Human Services (HHS) has compiled a draft non-exhaustive list of available ECPs for plan year 2018. These providers submitted an ECP petition by July 11, 2016, and were approved by CMS through the ECP petition review process. Nearly 1,000 federally certified RHCs have already been approved by HHS as ECPs.

You can see if you are on the approved ECP list by going to the searchable database and searching for your clinic by name.  If you are NOT on the list, you can petition to be an ECP by going to the ECP petition webpage.  If you are on the list and there is an error you would like to correct, you can do so on the ECP Petition webpage.

The Draft HHS ECP list for the 2018 benefit year is also embedded within ECP petition and can be viewed by clicking the button “Check to see if you are on the list” under question 6 of the ECP petition webpage

CMS is accepting petitions from qualified providers until 11:59 p.m. ET on October 15, 2016, for data corrections and additions to be considered for the 2018 ECP List.  RHCs who need technical assistance with the petition or may have general questions may receive assistance by emailing their question(s) to the following mailbox:

Providers should write “Comments on ECP Petition.” in the subject line of the email.  

Views – 434

HCPCS Reporting Requirements Starting Oct. 1st

CMS recently released a new MLN Matters article detailing the new HCPCS reporting requirements starting on October 1, 2016. The article can be accessed HERE.

As expected, we will no longer have to deal with a qualifying visit list. Instead, we will simply use the modifier “CG” to indicate to CMS which service line should be subject to coinsurance.

Nathan Baugh
Director of Government Affairs

Views – 354

RHC Chronic Care Mgm Claims

June 28, 2016
If you have been experiencing problems with your RHC CCM claims being paid incorrectly, the corrective action to “fix” the CMS claims processing system is schedule to be installed on July 11th. CMS has released the following statement. Note that the MAC should automatically reprocess any CCM claims that were paid the incorrect amount and no refiling of the claims on the part of the RHC is required.

Chronic Care Management Payment Correction for RHCs and FQHCs:
Effective January 1, Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs) began receiving payment for Chronic Care Management (CCM) services. Payment should be calculated based on the Medicare Physician Fee Schedule national average non-facility payment rate. CMS is aware that RHCs and FQHCs have been receiving a locality adjusted payment rate for CCM services. Your Medicare Administrative Contractor will adjust any claim processed incorrectly. No provider action is required.

Bill Finerfrock

Views – 425

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