Legislative Updates

Nov. 4, 2016
2017 Physician Fee Schedule Final Rule – RHC Provisions

While many of you were probably watching the Chicago Cubs win their first world series since 1908, we at the NARHC, were diligently reviewing the 2017 Physician Fee Schedule Final Rule for RHC related provisions.

These provisions are effective as of January 1, 2017. You can find the final rule here:

1-Supervision Requirement for RHCs Furnishing CCM Services (page 760-764)

CMS has finalized their change to the supervision requirement for CCM (Chronic Care Management) services furnished by RHCs. Effective January 1, 2017 RHCs may provide CCM and TCM services under the general supervision of a RHC practitioner.

2-Other CCM Changes (page 327)

There were numerous tweaks to the CCM scope of service. For those interested in the specific language of these changes, we have included a chart below which details the CY 2016 and CY 2017 scope of service requirements.

We should note that CMS is not allowing RHCs to bill for either one of the more complex CCM service CPT codes (99487 and 99489) or the separately billable CCM assessment and care planning code (G0506). NARHC will be reaching out to CMS to understand CMS’ rationale for prohibiting RHC CCM billing for the more complex CCM codes.  Once we have a better understanding of their thinking, we will determine how best to respond to this restriction.

3-Diabetes Prevention Program (page 1074)

The Diabetes Prevention Program (DPP) is a new benefit that CMS is expanding to the entire Medicare program beginning in 2018. We requested that CMS design the benefit in such a way that RHCs could bill for DPP services on a UB-04 form and not have to carve out costs of furnishing DPP from their cost report (a system similar to the CCM benefit).

Unfortunately, while CMS acknowledges that RHCs may enroll as MDPP suppliers, CMS clarified that they do not believe DPP services qualify as an RHC service. As currently structured, RHCs that chose to furnish DPP services would have to carve out all costs related to furnishing DPP services. This is a policy that makes adoption of DPP services in rural and RHC settings unnecessarily difficult.

The NARHC will be advocating that CMS reconsider this structure as they refine the DPP benefit for 2018 implementation.

CCM Scope of Service Requirements

CY 2016 CY 2017
Initiating Visit- Initiation during an AWV, IPPE, or face-to-face E/M visit for all patients (Level 4 or 5 visit not required). Initiating Visit- Initiation during an AWV, IPPE, or face-to-face E/M visit (Level 4 or 5 visit not required) for new patients or patients not seen within 1 year
Structured Recording of Patient Information Using Certified EHR Technology – Structured recording of demographics, problems, medications, medication allergies, and the creation of a structured clinical summary record, using certified EHR technology. A full list of problems, medications and medication allergies in the EHR must inform the care plan, care coordination and ongoing clinical care. Structured Recording of Patient Information Using Certified EHR Technology – Structured recording of demographics, problems, medications and medication allergies using certified EHR technology. A full list of problems, medications and medication allergies in the EHR must inform the care plan, care coordination and ongoing clinical care.
24/7 Access to Care- Access to care management services 24/7 (providing the beneficiary with a means to make timely contact with health care practitioners in the practice who have access to the patient’s electronic care plan to address his or her urgent chronic care needs regardless of the time of day or day of the week). 24/7 Access to Care- Provide 24/7 access to physicians or other qualified health professionals or clinical staff including providing patients/caregivers with a means to make contact with health care professionals in the practice to address urgent needs regardless of the time of day or day of week.
Continuity of Care- Continuity of care with a designated
practitioner or member of the care team with whom the
beneficiary is able to get successive routine appointments
Continuity of Care- Continuity of care with a designated member of the care team with whom the beneficiary is able to schedule successive routine appointments.
Comprehensive Care Management– Care management for chronic conditions including systematic assessment of the beneficiary’s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of beneficiary self-management of medications. Retained
Electronic Comprehensive Care Plan- Creation of an electronic patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional and environmental (re)assessment and an inventory of resources and supports; a comprehensive care plan for all health issues Retained
Electronic Sharing of Care Plan- Must at least electronically capture care plan information; make this information available on a 24/7 basis to all practitioners within the practice whose time counts towards the time requirement for the practice to bill the CCM code; and share care plan information electronically (by fax in extenuating circumstance) as appropriate with other practitioners and providers. Electronic Sharing of Care Plan- Must at least electronically capture care plan information, and make this information available timely within and outside the billing practice as appropriate. Share care plan information electronically (can include fax) and timely within and outside the billing practice to individuals involved in the beneficiary’s care.
Beneficiary Receipt of Care Plan– Provide the beneficiary
with a written or electronic copy of the care plan.
Beneficiary Receipt of Care Plan– A copy of the plan of care must be given to the patient or caregiver.
Documentation of care plan provision to beneficiary- Document provision of the care plan as required to the beneficiary using certified EHR technology Removed
Management of Care Transitions
-Management of care transitions between and among health care providers and settings, including referrals to other clinicians; follow-up after an emergency department visit; and follow-up after discharges from hospitals, skilled nursing facilities or other health care facilities.
-Format clinical summaries according to certified EHR technology (content standard).
-Not required to use a specific tool or service to exchange/transmit clinical summaries, as long as they are transmitted electronically (by fax in extenuating circumstance).
Management of Care Transitions
-Management of care transitions between and among health care providers and settings, including referrals to other clinicians; follow-up after an emergency department visit; and follow-up after discharges from hospitals, skilled nursing facilities or other health care facilities.
-Create and exchange/transmit continuity of care document(s) timely with other practitioners and providers.
Home- and Community-Based Care Coordination- Coordination with home and community based clinical service providers. Retained
Documentation of Home- and Community-Based Care Coordination- Communication to and from home- and community-based providers regarding the patient’s psychosocial needs and functional deficits must be documented in the patient’s medical record using certified EHR technology. Documentation of Home- and Community-Based Care Coordination- Communication to and from home- and community-based providers regarding the patient’s psychosocial needs and functional deficits must be documented in the patient’s medical record.
Enhanced Communication Opportunities- Enhanced opportunities for the beneficiary and any caregiver to
communicate with the practitioner regarding the beneficiary’s care through not only telephone access, but also through the use of secure messaging, Internet, or other asynchronous non face-to-face consultation methods.
Beneficiary Consent –
-Inform the beneficiary of the availability of CCM services and obtain his or her written agreement to have the services provided, including authorization for the electronic communication of his or her medical information with other treating providers.
-Inform the beneficiary of the right to stop the CCM services at any time (effective at the end of the calendar month) and the effect of a revocation of the agreement on CCM services.
-Inform the beneficiary that only one practitioner can furnish and be paid for these services during a calendar month.
-Document the beneficiary’s written consent and authorization using certified EHR technology
Beneficiary Consent –
-Inform the beneficiary of the availability of CCM services.
-Inform the beneficiary that only one practitioner can furnish and be paid for these services during a calendar month.
-Inform the beneficiary of the right to stop the CCM services at any time (effective at the end of the calendar month).
-Document in the beneficiary’s medical record that the required information was explained and whether the beneficiary accepted or declined the services.

Nathan Baugh
NARHC, Director of Government Affairs
(202) 544-1880
Email: Baughn@capitolassociates.com


July 13, 2016
2017 Physician Fee Schedule Updates

On July 6th, the Centers for Medicare and Medicaid Services (CMS) released the 2017 Physician Fee Schedule (PFS) proposed rule. This is one of the major annual rules CMS uses to announce proposed changes to the Medicare program. Most notably for RHCs, this year’s PFS makes numerous changes to the RHC Chronic Care Management (CCM) requirements, including changing the supervision requirement that we believe are welcome and should make it easier to implement CCM services.

Proposed Changes to CCM Requirements for RHCs

The most significant change to the RHC CCM benefit is a change to the supervision requirement from direct to general supervision. The rule states:

To enable RHCs and FQHCs to effectively contract with third parties to furnish aspects of CCM and TCM services, we propose to revise §405.2413(a)(5) and §405.2415(a)(5) to state that services and supplies furnished incident to TCM and CCM services can be furnished under general supervision of a RHC or FQHC practitioner. The proposed exception to the direct supervision requirement would apply only to auxiliary personnel furnishing TCM or CCM incident to services, and would not apply to any other RHC or FQHC services. The proposed revisions for CCM and TCM services and supplies furnished by RHCs and FQHCs are consistent with §410.26(b)(5), which allows CCM and TCM services and supplies to be furnished by clinical staff under general supervision when billed under the PFS.

This proposed change to general supervision would allow CCM services to be furnished by auxiliary personnel without the RHC practitioner in the same building. As the paragraph above alludes to, such a change would allow RHCs to contract with CCM vendors in the same manner as traditional offices.

CMS also proposed a number of other revisions to the CCM benefit designed to reduce administrative burden and improve payment accuracy for CCM services. These proposed requirements include:

Initiating Visit – Changing the requirement that the CCM service be initiated during an AWV, IPPE or comprehensive E/M visit where CCM services were discussed for all patients to only new patients or patients not seen within one year.

Editor’s note: This seemingly would allow for patients that have been seen by the RHC within the past year to have their CCM services be initiated at any visit. We believe this was CMS’s intention with this proposed change but we will be asking for clarification.

24/7 Access to Care – Clarifying that the 24/7 access requirement to care means “access to a RHC practitioner or auxiliary staff with a means to make contact with a RHC practitioner to address urgent health care needs regardless of the time of day or day of week.”

Care Plan Availability – Require timely electronic sharing of care plan information, but not necessarily on a 24/7 basis (as it is now), and allow transmission of the care plan by fax.

Care Transitions – Replacing the requirement that clinical summaries must be formatted to certified EHR technology, with the less burdensome requirement that the RHC must “create, exchange, and transmit continuity of care document(s) in a timely manner with other practitioners and providers.”

To see a full list of the changes CMS is proposing, please see page 183 of the proposed rule and the ensuing chart on page 187.

Supervision Requirement for Transitional Care Management (TCM) services

You may have noticed above that CMS is also proposing to change the supervision requirement for TCM services. As a reminder, TCM services are billable only when furnished within 30 days of hospital, SNF, or mental health center discharge. Within 2 business days, communication must be made by with the patient (may be phone/electronic/direct) and within 14 days a face-to-face visit must occur (7 days for CPT 99496).

CMS is now proposing that the communication-within-two-days-of-discharge part of the TCM benefit may now be performed by auxiliary staff under general supervision. However, the face-to-face visit aspect (within 14 or 7 days) of the benefit would still be retained as is. A TCM service and a CCM service cannot be billed during the same time period for the same patient.


The NARHC will be commenting in general support of these proposals. If anyone wants to submit their own comments, you may submit comments on www.regulations.gov by September 6, 2016.

If anyone has comments or questions, please feel free to reach out to Bill and myself.


Nathan Baugh
Director of Government Affairs
(202) 544-1880
Email: Baughn@capitolassociates.com


May 13, 2016
Coinsurance Correction Issued

In case you missed it. The following RHC updates were announced in the latest MLN eNews newsletter:

Coinsurance Correction for Certain RHC Claims
Effective April 1, 2016, Rural Health Clinics (RHCs) began reporting Healthcare Common Procedure Coding System (HCPCS) codes for all services furnished during the visit. CMS is aware that coinsurance may not be calculated correctly when RHC claims are submitted with multiple revenue lines for medical services. A system fix was implemented on May 9, 2016, to correct this issue. Your Medicare Administrative Contractor will adjust any claim processed incorrectly. No provider action is required.

Billing Requirements for RHCs
CMS understands that some Rural Health Clinics (RHCs) are unable to implement the billing requirements described in MLN Matters Article #9269 due to internal systems constraints. Contact your Medicare Administrative Contractor to find out if a temporary option is available while your system is updated.

Nathan Baugh
Director of Government Affairs


May 2, 2016
Qualifying Visit List to be Non-Exhaustive After Oct. 1

In case you missed it, (I know I did) there was a very significant change announced in the updated RHC QVL document:

The RHC QVL is intended as guidance for RHCs beginning to report HCPCS codes. It consists of frequently reported HCPCS codes that qualify as a face-to-face visit between the patient and an RHC practitioner and it is not an all-inclusive list of stand-alone billable visits for RHCs

…For dates of service on or after October 1, 2016, a medically-necessary service not on the current QVL can be billed as a stand-alone billable visit if the service meets Medicare coverage requirements, is within the scope of the RHC benefit, and is not furnished incident to a physician’s service.

As such, there is no longer a need for quarterly updates to the QVL. After Oct. 1, the modifier “CG” will alert CMS as to which service line includes the total charges that should be subject to coinsurance and deductible.

Also, please note CMS’ disclaimer:

NOTE: The use of a HCPCS code from the below QVL does not guarantee payment of the claim. All of the conditions for coverage and payment must be met for payment to be made. RHCs must retain adequate documentation of a patient’s condition and the services furnished as part of the patient’s medical record, which, along with the claim, may be subject to review by CMS, its contractors, or other oversight authorities.

Nathan Baugh


April 28, 2016
Qualifying Visit List Expanded and New FAQ

Yesterday, CMS released their updated and expanded qualifying visit list. The list contains a large number of new codes that will qualify RHC visits on their own.

Remember: If the visit is qualified solely by one of the codes listed in red, then you must wait until Oct. 1 to bill.


Additionally, CMS released a HCPCS FAQ that should clarify certain nuances in the reporting policy. While the whole FAQ is useful, I would especially review Questions 9 and 10 listed below:

Q9: How do RHCs report an E/M service and a medically-necessary service from the RHC QVL on a claim from April 1, 2016 through September 30, 2016?

A: From April 1, 2016 through September 30, 2016, RHCs should report the E/M service using the 052x revenue code with all the charges subject to coinsurance and deductible for the visit so that the charges for the visit should are rolled into the E/M service line. The medically-necessary service should be reported using the 052x revenue code with charges greater than or equal to $0.01. The E/M service line will receive the AIR and be subject to coinsurance and deductible.

Q10: Beginning on October 1, 2016, how do RHCs indicate which revenue code 052x and/or 0900 service line should receive the all-inclusive rate (AIR) and be subject to coinsurance and deductible?

A: Beginning on October 1, 2016, the Medicare Administrative Contractors (MACs) will accept modifier CG (policy criteria applied) on RHC claims. RHCs shall report modifier CG on one revenue code 052x and/or 0900 service line, which includes all charges subject to coinsurance and deductible for the visit. Modifier CG should only be used to indicate which revenue code 052x and/or 0900 service line should receive the all-inclusive rate (AIR) and be subject to coinsurance and deductible. Each additional service furnished during the visit should be reported with charges greater to or equal to $0.01. The additional service lines are for informational purposes only. The MACs will package/bundle the additional service lines, which do not receive the AIR.


Nathan Baugh, Director of Government Affairs


April 25, 2016
RHC Claims Fix

NARHC has confirmed with CMS that the FISS system fix that was causing claims to be held went in today, April 25, 2016.

Claims that have surpassed the 14 day processing period and were being held by CMS should begin to be released and paid today/tomorrow. If you have any claims from Date of Service April 1-April 11 that are still being held by Wednesday morning, please let us know.

Nathan Baugh
Director of Government Affairs
National Association of Rural Health Clinics
(202) 544-1880,  Baughn@capitolassociates.com


April 12, 2016
RHC Claims Being Held!

NARHC has been informed by CMS that due to significant problems processing claims under the FISS (Fiscal Intermediary Standard System), formerly known as the Florida Shared System (FSS) all Rural Health Clinic Medicare claims with a date-of-service on or after April 1, 2016 are being held by the Medicare Administrative Contractors (MACs).

At this time, we do not know how long this hold will be in place; however, we have been assured that this problem is being worked on as quickly as possible and officials at the highest level of CMS have been briefed on this development.  NARHC staff are scheduled to get an update on this later today and once we have new information, we will pass this along via listserve.

CMS is well aware of the significant financial problems delays in payments will cause RHCs and they have assured us they are exploring all options to either avoid or minimize payment delays.

Again, we will provide you with updates as soon as we get any additional relevant information from CMS on this delay.

If you have questions about this, please do not hesitate to contact us at:

bf@narhc.org and baughn@capitolassociates.com


March 23, 2016
RHC Qualifying Visit List Updated

Today CMS updated the RHC Qualifying Visit List by adding many (if not all) of the most common procedures performed in an RHC to the qualifying visit list of CPT codes. You can see the expanded list here:


RHCs are being asked to hold claims that are qualified solely by one of these procedure-code visits (listed in red) until October 1, 2016. The reason for this delay is related to the amount of time it takes for CMS to amend the system on their end.

Claims that are qualified by one of the initial qualifying visit codes (listed in black) but also include a procedure code (listed in red), will not have to be held until Oct. 1, 2016.

CMS is open to updating the RHC Qualifying Visit List on a quarterly basis as needed. You can subscribe to this webpage for updates: https://www.cms.gov/Center/Provider-Type/Rural-Health-Clinics-Center.html

Reminder: We will be hosting a RHC Webinar/TA Call on these new billing requirements Tuesday 3/29 at 1:30 pm EST. This call will be a great opportunity to learn about these new requirements and ask questions. There is no pre-registration required and the call-in info is below:

Webinar Link: https://hrsaseminar.adobeconnect.com/rhc-ta-webinar/
Conference number: 1-800-779-1416
Participant passcode: 4343459


December 4, 2015
Chronic Care Management Guide

The Centers for Medicare & Medicaid Services (CMS) has released a MedLearn Network Matters (MLN) article on the newly approved Rural Health Clinic, Chronic Care Management (CCM) benefit. The article outlines specific requirements & services the RHC must provide in order to qualify for the monthly CCM payment.

This is a helpful resource from CMS for those of you interested in providing CCM services to your Medicare patients. https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM9234.pdf

Also note that NARHC is working with CMS to present an RHC Technical Assistance webinar on the new Chronic Care Management Benefit.  Our intention is to hold this technical assistance webinar in January.

Stay tuned!  We will announce the specific date on the listserv once it is set.


November 20, 2015
PQRS Informal Review

Unfortunately CMS has not been able to definitively clarify how PQRS should work for EPs in RHCs. While the proposed rule from CMS clearly stated that EPs in RHCs we not subject to PQRS or the reporting requirements, many of you have received letters from CMS stating that you will indeed be subject to a negative PQRS payment adjustment.

I want to be very clear that this negative adjustment will only apply to claims that an EP submits on a 1500 form. RHC claims submitted via the UB-04 form will not be affected. For many of you, this is a relatively small portion of your claims, and appealing a 2% reduction on this portion may not be worth it. Nevertheless, those of you who would like to request an informal review of the reduction may do so at this link: CLICK HERE. The deadline is Dec. 11th.

Furthermore, we have drafted an Informal Review Form letter (CLICK HERE) for your convenience. If you have any questions on PQRS feel free to reach out.

Nathan Baugh
(202) 544-1880
Email: Baughn@capitolassociates.com


November 20, 2015
CY 2016 RHC Rate Announced

Earlier this week, CMS announced that the CY 2016 RHC rate will be $81.32. This is only applicable to those RHCs subject to the “RHC payment limit per visit” or otherwise known as the “RHC cap.”

This is a 1.1 percent increase from the CY 2015 RHC rate of $80.44. For the full announcement CLICK HERE.


November 16, 2015
Advanced Care Planning – New Benefit

In their final rule for the 2016 Medicare Physician Fee Schedule, CMS announced that beginning on January 1, 2016 Advanced Care Planning (ACP) services will be a stand-alone billable visit in a RHC.

RHCs furnish Medicare Part B services and are paid in accordance with the RHC all-inclusive rate system. Beginning on January 1, 2016, ACP will be a stand-alone billable visit in a RHC, when furnished by a RHC practitioner and all other program requirements are met. If furnished on the same day as another billable visit, only one visit will be paid. Coinsurance and deductibles will be applied for ACP when furnished in an RHC. Coinsurance and deductibles will be waived when ACP is furnished as part of an AWV.

Additional information on RHC billing of ACP is being developed by CMS and will be available in sub-regulatory guidance.

CMS has also released some examples of how billing for ACP and Chronic Care Management (CCM) will work on the rural health clinics center website.

There are two codes describing advance care planning services:

—-CPT code 99497:
Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; first 30 minutes, face-to-face with the patient, family member(s) and/or surrogate;

—-Add-CPT code 99498:
Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health professional; each additional 30 minutes (List separately in addition to code for primary procedure).

Technical Assistance Call with CMS planned for January

Be on the lookout for announcements regarding a webinar/call with CMS staff in January. The call will cover topics such as the HCPCS reporting requirement, billing for Chronic Care Management and billing for Advance Care Planning.


November 4, 2015
Deadline for Physician Quality Reporting System (PQRS) Informal Review Process

CMS is extending the 2014 Informal Review Period for those that believe they have been incorrectly assessed with a negative PQRS payment adjustment. The new deadline to submit an informal review is Dec. 11, 2015. You may read the full announcement here.

Unfortunately, there still seems to be confusion at CMS as to how they are applying the RHC exception to PQRS reporting. We are pressing CMS for answers but do not know exactly when we will have them.

Medicare Physician Fee Schedule 2016 Final Rule

On October 30, 2015 the Centers for Medicare and Medicaid Services (CMS) published the final rule for the 2016 Medicare Physician Fee Schedule responding to comments from the National Association of Rural Health Clinics among others and issuing their final policy. You may find our original memo on the proposed rule here. The following is a summary of the relevant sections of the final rule for Rural Health Clinics.

Chronic Care Management Benefit

CMS is moving ahead with the Chronic Care Management (CCM) benefit for Rural Health Clinics beginning on January 1, 2016 as expected. For an overview of the CCM benefit click here. With the final rule released and billing instructions soon to be finalized, NARHC is planning to offer additional technical assistance on the Chronic Care Management benefit for RHCs. Keep an eye on the listserv for an announcement soon.

CPT Code Reporting

CMS is moving forward with the Healthcare Common Procedure Coding System (HCPCS or CPT Code) reporting requirement for all RHC claims. However, CMS is delaying the effective date of this reporting requirement from January 1, 2016 to April 1, 2016.

PQRS Exemption for RHCs

Unfortunately, the PQRS eligibility of RHC providers providing non-RHC services is still unclear. It appears that CMS is using a more complex methodology to determine providers subject to the PQRS than they originally told us. We are pressing CMS for further clarification and will update the listserv as soon as we have a definitive understanding of CMS’s PQRS exemption methodology.


July 20, 2015
2016 Medicare Physician Fee Schedule Proposed Rule – RHC Relevant Sections

On July 8, 2015 CMS published the proposed rule for the 2016 Medicare Physician Fee Schedule.  We believe the following provisions are of interest to the National Association of Rural Health Clinics.

Proposed Chronic Care Management Benefit

As a part of their broader goal to integrate and coordinate services, CMS is proposing to extend the Chronic Care Management benefit to RHCs. Beginning on January 1, 2016 RHCs who furnish a minimum of 20 minutes per month of chronic care management (CCM) services to qualifying patients may begin billing for these services.  RHCs would also be subject to all the other requirements of providing CCM services such as having up-to-date EHR software, maintaining an electronic beneficiary care plan, and beneficiary consent.  You can find a primer on the current CCM benefit here.

The proposed rate for the CCM services will be based off the national average non facility payment rate for CPT code 99490 which was $42.91 per beneficiary per month in the first quarter of 2015.  In evaluating the payment methodology for the CCM benefit, CMS specifically noted comments submitted by the National Association of Rural Health Clinics. CMS proposes to waive the face-to-face requirement in order to allow CCM services to be billed as part of the RHC benefit.  We expect CCM services will be billed via the CPT code field on the standard UB 04 form. Further billing details will be released after adoption of a final rule later this year.

Absent any additional information that would change our view, re recommend NARHC support this proposal and submit comments affirming our support for this approach.

Proposed HCPCS Reporting Requirement for RHCs

CMS believes that requiring RHCs to report HCPCS (CPT) codes for all services would provide useful information on RHC patient characteristics, and the types of services being furnished by RHCs.  As such CMS is proposing that all RHCs must report all services furnished during an encounter using standardized coding systems beginning January 1, 2016.  The proposal requires an HCPCS (CPT) code to be reported along with the standard Medicare revenue code for each service furnished by an RHC to a Medicare patient.  CMS is inviting comments from RHCs on the feasibility of updating their billing systems to meet the proposed implementation date of January 1, 2016.

Absent any information suggesting that RHC Practice Management providers will be unable to upgrade or change their software in time, we recommend supporting this proposal.

Clarifying RHCs are not subject to PQRS Adjustments

CMS clarified that eligible professionals working in RHCs who perform non-RHC services (hospital inpatient visits, lab services, etc.) and bill Medicare Part B for these services, at RHCs are not subject to PQRS negative payment adjustments.

This is welcome news and recommend we communicate our appreciation & support to CMS for this information.

The Medicare Access and CHIP Reauthorization Act (MACRA) combines the PQRS, Meaningful Use, and Value Based Payment Modifier into one system called the Merit-Based Incentive Payment System (MIPS) beginning in 2019.  MACRA requires the Secretary to create a low-volume exception, to exclude certain professionals who might otherwise qualify from the MIPS program.  CMS is soliciting comments on what factor(s) should be used to establish this low-volume threshold.

Comments Solicited for MIPS Low-Volume Threshold Exception

We continue to review this proposal and have no recommendation at this time.

New Exception to Physician Kickback Rule

CMS is proposing a new exception to the Physician Kickback Rule to permit remuneration from a hospital, FQHC, or RHC to a physician to assist with employing a physician assistant (PA), nurse practitioner (NP), clinical nurse specialist (CNS), or nurse midwife (CNM). As currently proposed, the exception only applies when the PA/NP/CNS/CNM is a bona fide employee of the physician. As such, CMS is soliciting comments as to whether or not the exception should also apply to independent contractors. Additionally, CMS is soliciting comments on two methodologies to determine the geographic area served by FQHCs/RHCs. These definitions are intended to apply to RHCs/FQHCs in the same way that they apply to hospitals and rural hospitals, for purposes of the remuneration exception.

We welcome your thoughts on this. It appears to be a reasonable proposal but we’re not sure how important or significant this is for RHCs.

Ambulance Fee Schedule – Extension of the Super Rural Bonus

CMS is proposing to amend federal code in order to extend the “Super Rural Bonus” rate modifier for ambulance services through January 1, 2018 in accordance with MACRA.

Ambulance Fee Schedule – Staffing Requirement Revisions

Current staffing requirements require that Basic Life Support and Advanced Life Support ambulance providers must have two staffers present, but only one of these staffers must meet certain requirements. CMS is proposing to revise the staffing requirements such that all Medicare-covered (BLS and ALS) ambulance transports must be staffed by at least two people who meet the requirements of state and local law, in addition to the Medicare requirements. CMS believes these proposals would enhance the quality and safety of ambulances services provided to Medicare beneficiaries and strengthen the federal government’s ability to prosecute ambulance staffing violations.

Although not specifically an RHC issue, many of you are familiar with local ambulance services and we wondered if you had any thoughts on this. Will the additional staffing requirements (education/certification, etc.) adversely affect the availability of ambulance services in rural areas?


Comments must be submitted by 5 p.m. on September 8, 2015, you may submit comments electronically at www.regulations.gov

Nathan Baugh
Capitol Associates, Inc.


July 7, 2015
ICD-10 Update

Traditional coding conventions require that a claim be submitted using the diagnosis code the most accurately describes the medical condition for which payment is being sought.   This is true for ICD-9 and it will continue to be true for ICD-10.  However, because ICD-10 coding can be to a much higher degree of specificity than is currently available under ICD-9, there has been some concern that beginning October 1, 2015, Medicare will reject legitimate claims due to lack of specificity.  Yesterday, CMS released the following statement, clarifying that they will not enforce the “specificity” requirement for 12 months after the October 1, 2015 effective date.


The diagnosis code being used must still be supported by the documentation in the medical record and CMS will NOT accept an ICD-9 coded claim after October 1, 2015.  You are strongly encouraged to undertake ICD-10 testing with your vendors/payers where possible, to ensure their ability to appropriately accept and process an ICD-10 coded claim.  If your vendors/payers are unable to engage in ICD-10 testing, you would have reason to be concerned.  Furthermore, you should not simply accept at face-value assertions from  your vendors that they are ICD-10 ready.  Ask them for documentation to justify that assertion.


May 28, 2015
Veterans Choice Program

Click here for a Provider Application

Click here for a Facility Application

Click here to see if your provider has been added

January 30, 2015
Revised Guidance from CMS

The Centers for Medicare & Medicaid Services (CMS) has updated its interpretive guidelines in the following State Operations Manual (SOM) Appendices to reflect recent amendments to the applicable Conditions of Participation (CoPs), Conditions for Coverage (CfCs) and Conditions for Certification: o Appendix A – Hospitals o Appendix T – Hospital Swing Beds o Appendix L – ASCs o Appendix G – RHCs and FQHCs We are also taking this opportunity to update and clarify some portions of the existing guidance.

Effective Dates: The revised regulations and their associated guidance were effective July 11, 2014, with the exception of the RHC change concerning the requirement to employ at least one Nurse Practitioner (NP) or Physician’s Assistant (PMA); this latter change was effective July 1, 2014.

Memorandum Summary

  • Guidance Updated: The Centers for Medicare & Medicaid Services (CMS) has updated its interpretive guidelines in the following State Operations Manual (SOM) Appendices to reflect recent amendments to the applicable Conditions of Participation (CoPs), Conditions for Coverage (CfCs) and Conditions for Certification:

o Appendix A – Hospitals

o Appendix T – Hospital Swing Beds

o Appendix L – ASCs

o Appendix G – RHCs and FQHCs

We are also taking this opportunity to update and clarify some portions of the existing guidance.

  • Effective Dates: The revised regulations and their associated guidance were effective July 11, 2014, with the exception of the RHC change concerning the requirement to employ at least one Nurse Practitioner (NP) or Physician’s Assistant (PA); this latter change was effective July 1, 2014.

RHCs/FQHCs, 42 CFR Part 491

  • Definitions, §491.2

The definition of a “physician” has been revised to include a doctor of dental surgery or dental medicine, a doctor of podiatry or surgical chiropody, or a chiropractor, within the limitations of services these types of physicians are permitted to offer under Section 1861(r) Page 5 – State Survey Agency Directors of the Social Security Act. However, it continues to be the case that only MDs or DOs may fulfill the requirements for supervision, collaboration and oversight of non-physician practitioners in an RHC or FQHC.

  • Staffing and Staff Responsibilities, §491.8
  • 491.8(a)(3) was revised to permit an RHC to have a nurse practitioner or physician assistant provide services under contract to the RHC. This increased flexibility does not eliminate the longstanding statutory and regulatory requirement that the RHC must have at least one employee who is a nurse practitioner or physician assistant. This change was effective July 1, 2014.
  • 491.8(a)(6) was revised to require for RHCs that a nurse practitioner, physician assistant, or certified nurse-midwife is available to furnish patient care services at least 50% of the time the RHC operates. This aligns the regulatory language with the current statutory requirement. Note that since the statutory provision was self-implementing, CMS has enforced the 50% standard even prior to this regulation change. (See S&C 09-14)
  • 491.8(b) has been revised to delete the requirement formerly at §491.8(b)(2) for a physician to be present in the RHC or FQHC at least once every two weeks. This recognizes that many of the physician’s required functions may be performed remotely via electronic means, but does not remove the requirement that a practitioner, whether a physician or non-physician practitioner, must be present at all times the RHC or FQHC operates. Provisions formerly at §491.8(b)(1)(i) – (iii) have been renumbered to be §491.8(b)(1) – (3), but are otherwise the same.

We have also removed outdated material and clarified the guidance for §491.8.

CLICK HERE to read all


August 18, 2014
Preventive Services & RHCS
You & your patients won!

Late last week, CMS formally announced that they were rescinding a policy adopted earlier this year which denied payment for certain preventive services provided as stand-alone services when delivered in the RHC setting.  Although NARHC had been notified a few weeks ago by CMS officials that the reversal was going to take place, we decided to wait until CMS made the formal announcement before writing this message.

This change in policy by CMS comes about after intense pressure generated by NARHC, our members and friends and our bi-partisan Congressional Allies. I want to thank all of you who took the time to contact your Congressional offices to make them aware of the impact the change in policy was having on you and your patients.  While this is an important victory for the RHC community, it is even more important for your patients!

When the RHC Community acts together and engages our allies, we can successfully advocate for policy changes that improve your ability to provide quality healthcare and the ability of your community to enjoy a better quality of life.  I also want to take this opportunity to thank the CMS staff and Leadership for listening to the RHC community and acting to address our concerns.

According to the CMS announcement, ALL denied claims for the following preventive services back to January 1, 2014, should be resubmitted as an adjustment for appropriate payment.

Service HCPCS Code Long Descriptor Pd at the AIR Eligible for Same Day Billing Coinsurance/Deductible
Screening Pelvic Exam G0101 Cervical or vaginal cancer screening; pelvic and clinical breast examination Yes No Waived
Prostate Cancer Screening G0102 Prostate cancer screening; digital rectal examination Yes No Not Waived
Glaucoma Screening G0117 Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist Yes No Not Waived
G0118 Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist Yes No Not Waived

Eligible preventive services (identified above) shall be paid based on a RHC’s AIR when submitted on a 71X TOB with revenue code 052X.


July 31, 2014
ICD-10 Deadline for Compliance

Earlier this year, Congress adopted legislation that postponed the ICD-10 effective date from October 1, 2014 to a date – no sooner than October 1, 2015.  Because of the way the legislation was written, it left it up to the Secretary of HHS to set a new effective date.

For many months, CMS officials have stated publicly that it was their intent to set the new effective date for October 1, 2015.  However, until this date was published in the Federal Register, it was not official.

A short while ago, the Department of Health and Human Services issued a Final Rule officially setting the ICD-10 effective date as October 1, 2015.  In addition, HHS is also mandating continued use of ICD-9 through September 30, 2015.  By mandating use of ICD-9 through the end of September, 2015, individual payers cannot voluntarily seek to adopt ICD-10 prior to October 1 as some had suggested.

It is hoped that the additional time afforded the industry will be sufficient to ensure wide-spread industry readiness for adoption of ICD-10 by the new effective date.


July 18, 2014
New National Accrediting Organization – The Compliance Team

If you have clinics seeking RHC accreditation/certification, The Compliance Team is now officially approved as an accrediting agency for RHC certification.  Providing multiple non-governmental options for RHC certification is a tremendous achievement for NARHC and the RHC community.  This is a goal Ron Nelson and I set several years ago.  It is so gratifying that RHCs now have choices!  If you have any questions about their process, you are encouraged to contact The Compliance Team.  I hope you will join me in welcoming The Compliance Team as an official member of the RHC family!

Bill Finerfrock

79 FR 42019

Centers for Medicare & Medicaid Services

Medicare & Medicaid Programs; Initial Approval of The Compliance Team’s (TCT) Rural Health Clinic (RHC) Accreditation Program
AGENCY:Centers for Medicare and Medicaid Services, HHS.
ACTION:Final notice.

SUMMARY:This final notice announces our decision to approve The Compliance Team (TCT) for initial recognition as a national accrediting organization for Rural Health Clinics (RHCs) that wish to participate in the Medicare or Medicaid programs.
DATES: This final notice is effective July 18, 2014 through July 18, 2018.
FOR FURTHER INFORMATION CONTACT:Valarie Lazerowich, (410) 786-4750, Cindy Melanson, (410) 786-0310, or Patricia Chmielewski, (410) 786-6899.


July 11, 2014
Preventive Services billable when performed as stand-alone services in RHCs???

I wanted to take this opportunity to update you on our efforts to get CMS to recognize Medicare covered preventive services delivered as “stand-alone” visits in the RHC setting as billable RHC encounters. At this time, CMS policy has not changed.  CMS continues to instruct their Contractors to deny payment for most preventive services delivered as stand-alone visits when performed in the RHC setting.  The only exception to this policy at this time is the performance of the Introduction to Medicare  Physical (IPPE) and the Annual Wellness Visit (AWV).  These two services are billable as stand-alone services in the RHC.

However, on Wednesday (7/9), I met with the Director and Deputy Director of the Medicare program specially to discuss this policy, it’s ramifications for RHC patients and clinics and the intent of Congress in creating the preventive services benefit. Based upon our conversation, the CMS leadership has agreed to review and reassess the policy that denies these preventive visits as billable  visits when performed as stand-alone services in an RHC.  Although no timetable was set for when we can expect a response, I do not believe it will take a long time for them to complete the reassessment.

You should know that I left the meeting believing that the reassessment would be a sincere reexamination of the law and Congressional intent. Depending upon the outcome of that review, we will determine next steps.  I remain hopeful that CMS will find the latitude in the law to permit these preventive services visits to be billed when delivered as stand-alone visits.

In the event CMS continues to maintain that they do not have the statutory authority to make such a determination, then we have also agreed to work together to identify language that can be submitted to Congress to change the law such that it would give Medicare the statutory authority to cover these preventive services as stand-alone billable visits.  It is important that we continue to put pressure on CMS to ensure that Medicare beneficiaries receiving care in the RHC setting are not disadvantaged relative to their urban counterparts in their ability to easily access preventive services.

Please do not hesitate to contact me if you have any questions.

Bill Finerfrock


June 24, 2014
Annual Wellness Visits & IPPE

Recently, CMS announced that preventive services would no longer be considered medically necessary face-to-face visits when done in a RHC except for an Initial Preventive Physical Examination (IPPE) or the Annual Wellness Visit (AWV). Therefore, the only time the provider will be reimbursed their all inclusive rate when performing preventive services is when the provider performs an IPPE or AWV.

Below is the link to the revised MLN Matters Number SE1039 that clarifies how these preventive services should be billed.

Below is the link of Medicare preventive services that will be required to be performed with another medically necessary face-to-face visit or the preventive service will be denied except for the IPPE and AWV in RHCs.


May 29, 2014
Medicare Coverage of Preventive Services Provided in the RHC Setting

I am writing to alert you to a disturbing determination by CMS that will not only affect you as RHCs, but, more importantly, your patients.

Since 2011, Medicare has been covering certain preventive services.  In most instances the co-pay and deductible are waived as long as the patients and providers adhere to the frequency scheduled established for that particular preventive service.  This expansion occurred as a result of changes mandated by enactment of the Affordable Care Act.

Services such as Cervical or Vaginal Cancer screening; pelvic and breast examinations; and, screening pap smears have been covered as “stand-alone” services and billable as RHC visits in accordance with CMS published policy (see links below).



Recently, CMS announced that these services are no longer considered “medically necessary” face-to-face visits when performed in an RHC or FQHC and therefore not billable as stand-alone services.

Here is the specific language published by one of the Medicare contractors:  “…HCPCS G0101, Cervical or vaginal cancer screening; pelvic and clinical breast examination and Q0091, screening papanicolaou smear, are not considered to be a medically necessary face-to-face visits and will not be billed or paid at the all-inclusive rate when performed alone.”

The RHC/FQHC policy announcement goes on to state, “Claims billed with a preventive service code(s) that does not generate a separate payment without another covered service will be rejected”

What makes this determination particularly offensive is that CMS will continue to pay for these preventive services as stand-alone services when provided in other settings.  Here is how CMS describes coverage for screening pelvic exams in the non-RHC setting:

The screening pelvic examination benefit covered by Medicare is a stand-alone billable service.  It is separate from the Initial Preventive Physical Examination (IPPE) or the Annual Wellness Visit (AWV).  Medicare beneficiaries may obtain a screening pelvic examination at any time following Medicare Part B enrollment, including during their IPPE or AWV encounter.

In other words, if an otherwise healthy woman on Medicare living in a rural underserved area wants a screening pelvic exam as a stand-alone service and goes to a physician’s office in an urban area, Medicare will deem that service medically necessary and reimburse the physician 100% of the Medicare allowable charge for that service as a stand-alone service.  But if that same woman were to go to the RHC in her rural underserved community and have that screening pelvic exam performed as a stand-alone service, Medicare would deem the screening pelvic exam NOT medically necessary and deny the claim.

The idea that a service is NOT medically necessary if provided in an RHC or FQHC setting but IS medically necessary if provided in a non-RHC setting is absurd and offensive.  This represents a huge barrier for rural women and discourages them from obtaining care in RHCs and FQHCs.

I want you to know that NARHC is not taking this new policy lightly.  NARHC is requesting a meeting with CMS Administrator Marilyn Tavenner to discuss this policy and its ramifications for rural Medicare patients and we are letting our allies in Congress know about this gross misapplication of policy.

On May 30th, NARHC will be alerting our friends in Congress about this problem.  The principle health advisor for each Senator and Representative who is a member of the House and Senate Rural Caucus/Coalition will get a detailed message alerting them to this development and asking them for assistance.  I would ask that all of you consider contacting your Representative and Senators to reinforce the message we will be delivering. Please do not hesitate to share examples of how this policy will be harmful to Medicare beneficiaries if it is allowed to stand.

We will work to keep you informed of any progress we make in this area.
Bill Finerfrock, 202-544-1880, info@narhc.org


May 8, 2014
Preventive Services

Payments to RHCs for covered RHC services furnished to Medicare beneficiaries are made on the basis of an all-inclusive rate (AIR) per covered visit. Information on preventive services payable under the AIR is available in CMS Pub 100-04, Chapters 9 and 18.  The chart below lists preventive services that are eligible to be paid based on the provider’s AIR when billed without another covered visit.

Service HCPCS Code Long Descriptor Eligible service paid at the AIR Coinsurance/ Deductible CMS Pub 100-04
Initial Preventive Physical Examination (IPPE) G0402* Initial preventive physical examination; face to face visits, services limited to new beneficiary during the first 12 months of Medicare enrollment Yes Waived Ch 9 §150Ch 18 §80
Annual Wellness Visit G0438 Annual wellness visit, including PPPS, first visit Yes Waived Ch 18 §140
G0439 Annual wellness visit, including PPPS, subsequent visit Yes Waived

* This service is payable with another encounter/visit on the same day at the provider’s AIR.


May 7, 2014
Final Rule (Physician On-Site Hours, Telemedicine, etc.)

A short while ago, the Centers for Medicare and Medicaid (CMS) released “for public inspection” a regulatory relief final rule that includes an important change for RHCs.

As you know, RHCs have been required to have a physician on-site in the RHC a minimum amount of time as mandated by the federal government.  This, despite the fact that most state laws governing NP and PA practice permit the PA or NP to practice either independently/collaboratively for NPs or under remote/telephonic supervision for PAs.

Under the new rules, the federal minimum physician on-site requirement in the RHC rules is being modified such that RHCs will be required to follow state law or state regulatory requirements.  If there is no physician on-site requirement for NPs or PAs, then as long as the PA or NP is practicing in accordance with state law/state regulatory mechanism you will have satisfied the new requirement.

The NEW requirement goes into effect in 60 days from the date the Final Rule officially appears in the Federal Register.  That should be in a few days and we will announce that date once the final rule is published.

Other technical changes were made to “clean up” the RHC regulations and CMS officially responded to industry proposals dealing with other issues, such as regulatory relief on telemedicine.  We will be making an official response to the CMS response after we have had an opportunity to fully analyze the final rule.

In the meantime, we want to thank CMS for recognizing the unnecessary burden the physician on-site requirement was causing for RHCs and the acknowledgement that state laws were a better standard for ensuring the appropriate relationship between physicians and PAs and NPs.


May 1, 2014
ICD-10 Update

On April 1, 2014, the Protecting Access to Medicare Act of 2014 (PAMA) (Pub. L. No. 113-93) was enacted, which said that the Secretary may not adopt ICD-10 prior to October 1, 2015. Accordingly, the U.S. Department of Health and Human Services expects to release an interim final rule in the near future that will include a new compliance date that would require the use of ICD-10 beginning October 1, 2015. The rule will also require HIPAA covered entities to continue to use ICD-9-CM through September 30, 2015.


April 29, 2014
Independent Contractors

The Centers for Medicare and Medicaid Services (CMS) has released for “public display”, the final rule authorizing RHCs to contract with some PAs and NPs via an independent contractor relationship.  This policy change was included in a much larger rule changing the way FQHCs are reimbursed under Medicare.  The new RHC policy will take effect on July 2, 2014, 60 days after it appears in the federal register (May 2nd).

The new policy will amend the RHC regulations to permit RHCs to contract with PAs and NPs as long as ONE PA or NP working in the RHC is an employee of the clinic.  CMS has previously maintained that the RHC statute requires that ALL PAs and NPs working in the RHC must be employees.  The new policy clarifies that only one PA or NP must be an employee.  All other PAs or NPs working in the RHC can employees OR independent contractors.

Although the policy does not go as far as NARHC had recommended – we proposed that ALL PAs and NPs working in the RHC could be “employed” as independent contractors – we are pleased that CMS is providing this level of flexibility.  In response to the NARHC recommendation, CMS maintains that the RHC law does not permit them to go as far as we recommended.  Therefore, CMS states that any additional changes the RHC community might seek in this area would have to be pursued via the Congress.

Additional changes in the RHC rules providing added flexibility are expected to be released by CMS in the very near future.  One of the expected changes will be a relaxation of the RHC physician on-site requirement to reflect state law rather than the current federal minimum physician on-site requirement.  NARHC will announce those changes as soon as they are released by CMS.


March 31, 2014
SGR Patch/ICD-10 Delay

The United States Senate has joined the House of Representatives and passed legislation to prevent a 24% cut in physician fee schedule payments from occurring tomorrow (4/1) as previously scheduled.  Instead, Medicare physician fee schedule payments will continue to be paid as they have been for the past 3 months.   Although the legislation must be signed by the President in order to become effective, the President has indicated that he will sign this legislation once it reaches his desk.

In addition to preventing the SGR related reduction, Congress approved language extending various other Medicare provisions slated to expire at Midnight tonight.  These include:

Extends Medicare work Geographic Practice Cost Index (GPCI) floor for 1 year

  • Extends      Medicare therapy cap exception process for 1 year
  • Extends      Medicare ambulance add-on payments for 1 year
  • Extends      Medicare adjustment for Low-Volume hospitals for 1 year
  • Extends      Medicare-dependent Hospital (MDH) program for 1 year

In addition to these “extenders” Congress also approved a one-year delay in the effective date of the ICD-10 transition.  As you know, ICD-10 has been scheduled to take effect on October 1, 2014.  Due to Congressional intervention, the new effective date will be October 1, 2015.


January 6, 2014
Medicare Benefit Policy Manual Change…

CMS issued a change request for MLN Article MM8504 with changes to the Medicare Benefit Policy Manual – RHC and FQHC Update – Chapter 13.

Effective January 1, 2014 the venipuncture will be included in the all-inclusive rate and will not be separately billed to Medicare Part B. 

Here is the section from the article that reflects the change:

  • Although RHCs and FQHCs are required to furnish certain laboratory services (for RHCs see section 1861(aa)(2)(G) of the Act), and for FQHCs see section 330(b)(1)(A)(i)(II) of the PHS Act), laboratory services are not within the scope of the RHC or FQHC benefit. When clinics and centers separately bill laboratory services, the cost of associated space, equipment, supplies, facility overhead and personnel for these services must be adjusted out of the RHC or FQHC cost report. This does not include venipuncture, which is included in the all-inclusive rate when furnished

Link to the article:   MM8504


December 17, 2013
RHC Upper Payment Limit for 2014

CMS has officially announced that the 2014 RHC upper payment limit (aka cap) will be $79.80 per visit.  This represents a .8% increase over the 2013 Upper Payment Limit of $79.17 per visit.  The RHC cap does not apply to provider-based RHCs owned by hospitals with fewer than 50 beds.  This new cap is effective for services delivered on or after January 1, 2014. Please contact your Medicare Administrative Contractor if you have questions about this new cap.


December 2, 2013
Updates to Chapter 13 – Medicare Benefit Policy Manual
This link is an article on a CMS change request that advises MACs to updates to Chapter 13 of the “Medicare Benefit Policy Manual.” The updates include new information on transitional care management and hospice payment exceptions, RHC employment, and provides clarification of existing information.



November 5, 2013
Billing Behavioral Health Services

A Master’s level Clinical Social Worker is a recognized provider in the RHC setting.  It is not sufficient that the individual be licensed by the state.  He/she must have the minimum educational credential of a Master’s degree as a Clinical Social Worker.

Mental health services within the scope of practice for the CSW are covered as RHC mental health visits to the extent the visit is face-to-face, medically necessary and otherwise covered by the Medicare program.  The payment adjustments applicable to mental health services would apply.

Note that beginning January 1, 2014, there will no longer be a mental health adjustment.  Mental health services covered by Medicare will be paid the same as medical services (i.e. 80% of allowable or cost-based rate).


September 12, 2013
ALL Employers Required to Notify Their Employees of Health Insurance Options!

A little noticed provision in the Patient Protection and Affordable Care Act (ACA) requires ALL employers to notify their employees of the health insurance options they have available to them as a result of enactment of the ACA.  According to the Department of Labor, all employers covered by the Fair Labor Standards Act (FSLA) are obligated to make the health insurance notification by OCTOBER 1, 2013.  An FSLA covered employer is one with at least one employee and $500,000 in revenue.

This notification MUST occur whether the employer provides health insurance to the company’s employees or not.  The Department of Labor has provided information about this mandatory notification and made model forms available for employers to use.

Here are the links:

One for employers that DO offer health insurance:

One for employers that DO NOT offer health insurance:

Spanish language versions of these model forms are also available for download.

There is some work involved in being able to accurately complete the form – particularly for employers that offer health insurance.  This is not a simple “cut and paste” exercise.

The notification must be in writing AND written in manner that can be expected to be understood by the “average” employee.  The written notification can be hand delivered or it may be sent to the employee via first class mail or electronic mail.  Although employers are not required to obtain written verification from the employee indicating receipt of the notice, employers may wish to obtain verification in the event there is a question.

Failure to make the required notification could result in a fine of up to $100.00 per day.

For new employees (those hired after 10/1/2013), the communication must be given to new employees within 14 days of the beginning of their employment.  There is also An ACA notification requirement when an employee leaves if that employee is eligible for COBRA benefits.

To learn more about the employee notification requirement, you can also visit the Department of Labor’s website: http://www.dol.gov/ebsa/newsroom/tr13-02.html


Electronic Eligibility Verification Function

As of January 1, 2013, ALL health plans, including Medicaid, are required under HIPAA and the Affordable Care Act to have an electronic eligibility verification function (270/271) available.

Plans are required to have a “real time” eligibility verification system as part of the transaction code set standards and the operating rules.  Under the operating rules standards, the Health Plan must respond (271) to an electronic eligibility verification inquiry (270) in less than 20 seconds. You should ask your health plans how you go about connecting with the plan to do electronic verification and what information they will require in order to process the inquiry.  This is particularly important for Medicaid plans where eligibility can change on a month-to-month basis.

If you use a billing service or clearinghouse to submit claims, either should be able to assist you.  If you have a practice management program, you should also contact your practice management vendor to ask about whether their software supports electronic transaction inquiries such as eligibility verification, claims status, etc.

If a payer tells you that they cannot support a 270/271 eligibility inquiry/response, they are in violation of the HIPAA and ACA requirements and you can file a complaint against the payer.


April 24, 2013
RE: Revised HIPAA Privacy Standards

In January, the Department of Health and Human Services issued newly revised HIPAA privacy standards. These new standards went into effect in late March but they will not be enforced until late September.  Several changes were made to ensure even greater privacy of Protected Health Information (PHI).

Click HERE for a link to the final rule.

The new HIPAA standards grant individuals the right to restrict disclosure of PHI to Health Plans for treatment the patient received for which the individual paid in full (i.e. no Health Plan payment was received).

The idea is that this is the patient’s information and the insurance company has no legal right to that information because the insurance company did not pay for that healthcare.  In the past, this information was generally disclosable because Health plans could use this as part of their underwriting efforts.  Given that health insurers can no longer “experience rate” health insurance premiums based upon health status and cannot deny health insurance due to a pre-existing condition, there is no reason that the insurance company would need to know about any healthcare the individual paid for out-of-pocket.


March 8, 2013
Re:  Medicare Claims Processing & Sequestration; Reducing Regulatory Burden for Rural Health Providers

As you know, on March 1st, President Obama issued a sequestration order as required by the Budget Control Act of 2011.  Although for most federal programs the effects of sequestration began immediately, for Medicare Part A and Part B, the sequestration related cuts do not take effect until April 1st.

For Medicare Part B, CMS has been ordered to reduce Medicare outlays for 2013 by $5.1 Billion dollars.  For Part A, the sequester related reduction is $5.6 Billion

Here is the CMS Guidance explaining how they intend to comply with the sequestration order:

Mandatory Payment Reductions in the Medicare Fee-for-Service (FFS) Program – “Sequestration”

The Budget Control Act of 2011 requires, among other things, mandatory across-the-board reductions in Federal spending, also known as sequestration. The American Taxpayer Relief Act of 2012 postponed sequestration for 2 months. As required by law, President Obama issued a sequestration order on March 1, 2013. The Administration continues to urge Congress to take prompt action to address the current budget uncertainty and the economic hardships imposed by sequestration.

This listserv message is directed at the Medicare FFSprogram (i.e., Part A and Part B). In general, Medicare FFSclaims with dates-of-service or dates-of-discharge on or after April 1, 2013, will incur a 2 percent reduction in Medicare payment. Claims for durable medical equipment (DME), prosthetics, orthotics, and supplies, including claims under the DMECompetitive Bidding Program, will be reduced by 2 percent based upon whether the date-of-service, or the start date for rental equipment or multi-day supplies, is on or after April 1, 2013.

The claims payment adjustment shall be applied to all claims after determining coinsurance, any applicable deductible, and any applicable Medicare Secondary Payment adjustments.

Though beneficiary payments for deductibles and coinsurance are not subject to the 2 percent payment reduction, Medicare’s payment to beneficiaries for unassigned claims is subject to the 2 percent reduction. The Centers for Medicare & Medicaid Services encourages Medicare physicians, practitioners, and suppliers who bill claims on an unassigned basis to discuss with beneficiaries the impact of sequestration on Medicare’s reimbursement.

Questions about reimbursement should be directed to your Medicare claims administration contractor. As indicated above, we are hopeful that Congress will take action to eliminate the mandatory payment reductions.


January 22, 2013
RE:   New RHC Billing “cheat sheet”

CMS recently published a “cheat sheet” for rural provider billing, including RHCs (both independent and provider-based). The document covers billing Medicare for traditional RHC services as well as how (and to whom) RHCs should bill Medicare for non-RHC services.  In addition to RHC billing, the document covers billing for: CAHs, SNFs, Home Health, FQHCs.
There are both “quick reference” charts, as well as more detailed billing charts for each of the providers listed above.  You may want to download this document and make it available to your billing staff.


January 2, 2013
Re:  Fiscal Cliff/SGR Update

Yesterday, the United States Congress approved legislation that prevents most taxpayers from experiencing a tax increase; prevents the scheduled 26.5% SGR related cut in physician fee schedule payments; and delays (until early March) the 2% across-the-board cut in Medicare payments due to sequestration.

In lieu of the 26.5% SGR cut, the Congress approved a one-year freeze in the Medicare conversion factor used to calculate Medicare Physician Fee Schedule payments.  The Congress also approved a one-year extension of several Medicare payment policies that were set to expire.  Finally, the Congress approved a series of payment reductions in other provider payments as a way to “pay for” the SGR fix.

Other than the 2% sequester cut that has been delayed, none of these changes directly affects RHCs.  However, we thought it would be helpful to make you aware of these changes as many RHCs are part of larger organizations (hospitals, CAHs, group practices, etc.) that may be affected by some of these changes.

A list of the Medicare provisions “extended” is below, along with the list of payment reductions the Congress approved as “offsets”.

Medicare Provider Payment provisions extended as part of the Fiscal Cliff compromise.

Work Geographic Adjustment. This provision extends the existing 1.0 floor on the “physician work” index through December 31, 2013.

Payment for Outpatient Therapy Services. This provision extends the exception process through December 31, 2013. The provision also extends the cap to services received in hospital outpatient departments only through December 31, 2013.

Ambulance Add-On Payments. This provision extends the add]on payment for ground including in super rural areas, through December 31, 2013, and the air ambulance add]on until June 30, 2013.

Extension of Medicare inpatient hospital payment adjustment for low volume hospitals. This provision extends the payment adjustment until December 31, 2013.

Extension of the Medicare-Dependent hospital (MDH) program. This provision extends the MDH program until October 1, 2013.

Other Health Provisions used to offset the cost of a temporary SGR fix.

Documentation and Coding (DCI) adjustment. This provision will phase in the recoupment of past overpayments to hospitals made as a result of the transition to Medicare Severity Diagnosis Related Groups (MS]DRGs). Savings: $10.5 billion.

Rebase End Stage Renal Disease (ESRD) payments. This provision incorporates recommendations from the General Accountability Office by re]pricing the bundled payment to take into account changes in behavior and utilization of drugs for dialysis. Savings: $4.9 billion.

Therapy Multiple Procedure Payment reduction. This provision further reduces payment for subsequent therapies when therapies are provided on the same day. Savings: $1.8 billion.

Payment for Certain Radiology Services. This provision would equalize payments for stereotactic radiosurgery services provided under Medicare hospital outpatient payment system. Savings: $0.3 billion.

Adjustment of Equipment Utilization Rate for Advance Imagining Services. This policy would increase the utilization factor used in the setting of payment for imaging services in Medicare from 75% to 90%. Savings: $0.8 billion.

Competitive Prices for Diabetic Supplies. This proposal would apply competitive bidding to diabetic test strips purchased at retail pharmacies. Savings: $0.6 billion.

Adjust Payment Adjustment for Non-Emergency Ambulance Transports For ESRD Beneficiaries. This provision reduces the payment rates for ambulance services by 10% for individuals with ESRD obtaining non]emergency basic life support services involving transport, based on a recent General Accountability Office report. Savings: $0.3 billion

Increase statute of limitations for recovering overpayments. This provision increases the statute of limitations to recover overpayments from three to five years, based on recommendations from the Office of Inspector General at the Department of Health and Human Services. Savings: $0.5 billion.

Medicare Improvement Fund. This provision eliminates funding for the Medicare Improvement Fund. Savings: $1.7 billion.

Rebase Medicaid Disproportionate Share Hospital (DSH) payments to extend the changes from the Affordable Care Act (ACA) for an additional year. This proposal rebases DSH allotments to maintain the level of changes achieved in the ACA, and determines future allotments off of the rebased level using current law methodology. Savings: $4.2 billion.

Repeal of Class Program. The provision repeals the Community Living Assistance Services and Supports (CLASS) program established by the Affordable Care Act. This provision has no scoring implications.

Coding Intensity Adjustment. Under current law, Medicare Advantage plans receive riskadjustment payments that are further adjustment to reflect differences in coding practices between Medicare fee-for-service and Medicare Advantage. This provision increases this coding intensity adjustment. Savings: $2 billion.

Consumer Operated and Oriented Plan (CO-OP). This provision will rescind all unobligated CO]OP funds under section 1332(g) of the Affordable Care Act. This provision also creates a contingency fund of 10 percent of the current unobligated funds to be used to further assist currently approved co]ops that have already been created. The provision does not take away any obligated CO]OP funds. Savings: $2.3 billion.




The Centers for Medicare & Medicaid Services (CMS) today (6-26-08) issued a proposed rule to update certification and participation regulations and payment provisions for Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs). The rule would establish location requirements and exception criteria for RHCs; revise the RHC and FQHC payment methodology; require RHCs to establish a quality assessment and performance improvement (QAPI) program; allow RHCs to contract with RHC non-physician providers under certain circumstances; and propose other changes to update the regulations to clarify existing requirements, provide the opportunity to make program improvements, and comply with statutory requirements.

Click here for the Summary of the New Rule (5 pages).

Click here for the New Rule in detail (103 pages).

Click here for the Medicare Fact Sheet

Click here for the Shortage Area Rule and RHC Rule Update (message from Bill Finerfrock)

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