October 29, 2018

On October 24th, President Trump signed into law the “SUPPORT for Patients and Communities Act.” This legislation represents the culmination of bipartisan efforts to combat the opioid crisis gripping our country. In an otherwise partisan environment, the SUPPORT for Patients and Communities Act passed the Senate (98 to 1) and the House (396 to 14) with overwhelming bipartisan majorities.

The legislation contains a wide array of policy changes and is the combination of many smaller pieces of legislation all aimed at different aspects of the opioid epidemic. Majority Leader McConnell described the legislation on the Senate floor as “the collaborative product of contributions from 70-plus members of this body. Five different committees had a say. The result is a landmark package that will deliver critical resources to establish opioid-specific recovery centers and equip local medical practitioners. It will help law enforcement stop the flow of opioids across borders and increase safeguards against overprescription.”

Despite strong support in Congress, some critics charge the legislation does not go far enough. Senator Elizabeth Warren (D-MA), supported the final package but noted in her statement that “Congress could have gone further in providing communities with the resources they need to address the epidemic, I supported this bill because it makes some common-sense changes that will help us in our fight against the opioid crisis.”

There is one provision specifically directed towards Rural Health Clinics in the bill. Section 6083 of the legislation designates two million dollars for RHCs to cover the costs of practitioners obtaining a “DATA 2000 Waiver.” Physicians or practitioners need this waiver to administer buprenorphine as part of an opioid dependency treatment plan.

Physicians or practitioners who are interested in practicing opioid dependency treatment, must follow the waiver process and undergo the required training as described here.

The details about how RHC physicians or practitioners can apply for the grant, including the total amount of the grant payment, will be promulgated in forthcoming rulemaking by the Secretary of Health and Human Services. We expect that RHCs will be able to apply for these funds sometime in 2019.

While physicians groups such as the AMA were largely supportive of the opioid legislation, there are a few provisions that concern provider groups. For instance, section 2003 of the law requires that all schedule II, III, IV, and V controlled substances under Medicare part D be prescribed electronically by January 1, 2021. The AMA opposed this mandate on the grounds that it was duplicative with other federal and state prescribing regulations.

Nathan Baugh,
(202) 543-0348

October 1, 2018

On September 20th, a small contingent of individuals from across the Rural Health Clinic (RHC) community and country came to Washington D.C. for a series of meetings with Congress on modernizing the RHC statute. This “fly-in” was organized and coordinated by NARHC as part of an effort to build support for legislation that we hope will pass this year or early next year.

Jeff Harper from the RHC consulting firm inQuiseek was one of the attendees. “For NARHC’s first Fly-in,” Jeff tells me, “we were encouraged by the welcome we received from each legislative office. The Hill expressed a real interest in knowing more about RHCs and how they can assist us in providing healthcare to the rural communities we serve and they represent.”

The RHC community already knows this, but the RHC statute is in dire need of modernization. As we explained to Congress, medicine has evolved since 1977, but RHC laws have not. A tentatively titled “RHC Modernization Act of 2018” is currently circulating around the Hill in draft form and it addresses many of the outdated aspects of the RHC statute.

While healthcare issues are often very controversial, we have heard that modernizing the RHC program is by-and-large a popular and bipartisan issue. I asked Amanda Shelast, a Regional Clinic Director for Aspirus in Michigan, to gage how she thought her meetings went.

“I had the honor of hitting Capitol Hill with Teresa [Treiber] from Spectrum Health in Michigan.” Amanda explains, “In speaking with each of the offices, we felt good about gaining support and traction for our modernization proposals.”

The draft bill includes vital updates to the RHC statute such as raising the cap on RHC reimbursement and allowing RHCs to bill as distant site providers under the Medicare telehealth benefit. The legislation also fixes outdated provisions such as the RHC lab requirements and certain physician supervision rules in PA-led or NP-led clinics.

Dr. Keith Davis from Shoshone Family Medical Center in Shoshone Idaho gave me an upbeat report.

“All NARHC recommendations seemed straightforward to the staffers,” Dr. Davis writes, “even section 6 (to raise the RHC cap incrementally) made sense to the staffers, given that traditional Medicare will exceed the RHC rate by 2019 if nothing is done. Clearly NOT the intent of the RHC program!”

Looking forward, our objective is to build additional support for this legislation in Congress. In order to do that effectively, we will need help from you ~ the RHC community. As always, we encourage RHCs to reach out to their Members of Congress and engage them on RHC issues as often as they can.

Additionally, once the legislation is formally introduced, we will be organizing a grassroots advocacy campaign whereby we will be asking Members of Congress to cosponsor and support the legislation. Your participation will be crucial to that campaign’s success. Please be on the lookout for info from NARHC regarding the next steps.

Finally, I would like to acknowledge and thank everyone who volunteered their time and money to come to Washington D.C. to advocate for Rural Health Clinics:

  • Angie Charlet – Illinois
  • Dr. Keith Davis – Idaho
  • John Gill – Florida
  • Patty Harper – Louisiana
  • Jeff Harper – Louisiana
  • Kate Hill – Pennsylvania
  • Charles James – Missouri/Illinois
  • Jennifer O’Riley – Texas
  • Amanda Shelast – Michigan
  • Teresa Treiber – Michigan

Nathan Baugh, Kate Hill, Teresa Treiber, Jennifer O’Riley, Patty Harper, Jeff Harper, Angie Charlet, Charles James, Jr., Dr. Keith Davis, Bill Finerfrock, John Gill, Amanda Shelast

September 21, 2018

CMS released a proposed rule on September 20th seeking to reduce unnecessary regulatory burdens within the Medicare program. The goal of the proposal is to allow health care professionals to focus more resources and time on providing care by reducing regulatory requirements that might impede that.

NARHC is happy to see that CMS has listened to our concerns and has included several proposals to reduce burdens for Rural Health Clinics (RHCs).

In the last few years, RHCs have had an influx of new regulations and guidelines to comply with. From emergency preparedness to Affordable Care Act non-discrimination rules to the new interpretive guidelines in appendix G for survey and certification, it seemed like the regulatory relief agenda was never coming to the RHC program.

However, this proposed rule may finally bring some much-needed burden reduction to the RHC program. Amongst the RHC-specific changes are:

Changing the annual review of patient care policies and program evaluations to an every-other-year requirement.

Allowing facilities to review their Emergency Preparedness program every other year instead of every year.

Eliminating the requirement that RHCs must document their communication with emergency preparedness officials.

Allowing facilities to train their staff on emergency preparedness every other year.

Reducing the number of emergency preparedness exercises required per year to one.

CMS is seeking feedback on these specific proposals.

CMS is also soliciting ideas from the public on regulatory relief within the Medicare program. NARHC plans to submit comments to CMS with suggestions on additional ways to reduce burden on RHCs.

We encourage the RHC community to submit their own comments because the more CMS hears from RHCs the more likely it is that we can get CMS to finalize this regulatory relief. You can submit comments here:

Comments are due by November 19th, 2018.

Nathan Baugh, (202) 543-0348

August 23, 2018

Q: The information I’ve seen regarding new Medicare payment proposals includes an option to pay a flat rate (proposed fee $93). That certainly sounds like what we already have as an RHC with our AIR, and without jumping through RHC hoops. And that proposed rate is higher than the current cap for the AIR for independent RHC’s. If this goes through, what would be the point of continuing as an RHC for Medicare? I’m curious how others are viewing this proposal. Surely it would result in an increase in the cap for RHC’s.

A: It is an interesting question and one that we (NARHC) leadership and staff have discussed.

I think first and foremost would be that dropping RHC status and going to traditional Medicare fee-for-service would also mean losing the RHC Medicaid payments.  I think in most instances, RHC Medicaid payments are much better than traditional Medicaid payments in most states.  So depending upon your payer mix (Medicare and Medicaid) the financial gains you might realize on the Medicare side if you dropped RHC status, could be negated by the financial  losses you could experience for care provided to Medicaid recipients.

Second, depending upon your staffing, the financial gains might not be as attractive as you think if you plan to continue to utilize PAs and NPs in your care model.  Remember, unlike a Rural Health Clinic visit, where the Medicare/Medicaid payments are the same regardless of whether the visit is performed by a physician or a PA or NP, under traditional Medicare, the Medicare allowable is 85% of the physician fee schedule amount when the service is provided by a Physician Assistant or Nurse practitioner.  So if you take the fee-for-service proposed rate of $93 for a physician and apply the 15% PA/NP the allowable would be $79.05 – less than the 2018 RHC Cap.

Finally, there may be other programs linked to your RHC status that could be having a positive impact on the financial viability of your clinic that would be lost if you gave up your RHC status.

The question you didn’t ask but that is relevant to this communication:  What is NARHC doing with respect to the RHC Cap?

NARHC has long supported an increase in the Cap and continues to advocate for this change.  We believe the cap should be raised to at least $115.00 – $120.00 per visit to reflect the current cost-per-visit as determined by the RHC cost reports.  The HHS National Advisory Committee on Rural Health and Human Services, at the urging of NARHC, has recommended that the Trump Administration support raising the RHC Cap.  The U.S. Senate Rural Caucus has previously endorsed raising the RHC cap and many individual Members of Congress have voiced their support as well.

In September, a group RHC representatives (NARHC Board and Policy Committee) from around the country will be traveling to Washington DC to meet with their elected officials to talk about the cap and other changes in the RHC program we would like to see made.

In addition, we will be reaching out to the RHC community in the next few weeks encouraging you to write to your elected representatives in Washington DC, to simultaneously support the work of those who will be on Capitol Hill doing face-to-face meetings with House and Senate offices.

NARHC is committed to getting the Rural Health Clinic Cap increased to a level that more closely approximates the cost of providing services to Medicare beneficiaries residing in rural underserved areas.  Your support for our efforts is greatly appreciated.

Bill Finerfrock
NARHC Executive Director


August 4, 2018

The following message is posted on the Palmetto website.

Palmetto GBA and CMS have received a number inquiries from providers and their representatives concerning provider appeal rights as well as information on how impacted providers may re-bill responsible MA plans. CMS is working to address these concerns and provide information to MA plans that will help them be better able to identify any rebilled claims from providers. So as to afford the agency with the time needed to develop complete guidance on these topics, CMS has requested that Palmetto GBA indefinitely delay its’ plans to auto-cancel claims for providers who have not submitted a valid exception request by August 17th.  Additional information will be forthcoming in the next few weeks. Please review this information and share it with your staff.

NARHC has been working with CMS staff to resolve this mess in a way that will not be harmful to RHCs and their patients. Other groups, representing physicians, hospitals and others have joined us in this effort. We are pleased that CMS has decided to suspend recoupment indefinitely until we can put a process in place that resolves ALL of the issues – in particular the timely filing problems and resubmitting claims to MA plans.

While this announcement does not resolve the problem, it does provide much needed time to work out a permanent solution that does not harm RHCs or their patients.

We will continue to work with CMS and other stakeholder groups and their legal counsel until this matter is resolved.

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

Bill Finerfrock


July 13, 2018
CMS Proposes New “Virtual Check-In” and “Remote Evaluation” Benefit for RHCs

Despite the fact that Rural Health Clinics are not paid under the physician fee schedule, significant updates and changes for the RHC program are often included in the Physician Fee Schedule rulemaking process. Yesterday, CMS released their thousand-plus page 2019 Physician Fee Schedule proposed rule. One major takeaway for RHCs is the proposal of a new “virtual check-in” service. CMS describes this as a service where “a physician or non-physician practitioner has a brief (5 to 10 minutes), non-face-to-face check in with a patient via communication technology to assess whether the patient’s condition necessitates an office visit.”

This new “virtual check-in” benefit is the latest non-face-to-face service adopted by Medicare as it seeks ways to lower cost and improve access to health care through technology. CMS states that they “now recognize that advances in communication technology have changed patients’ and practitioners’ expectations regarding the quantity and quality of information that can be conveyed via communication technology.” This service can only be billed when “medical discussion or remote evaluation is for a condition not related to an RHC or FQHC service provided within the previous 7 days, and does not lead to an RHC or FQHC service within the next 24 hours or at the soonest available appointment, since in those situation the services are already paid as part of the RHC or FQHC per-visit payment.”

Additionally, CMS proposes to pay practitioners for a similar “remote evaluation service” which CMS describes as the remote evaluation

of patient-transmitted information conducted via pre-recorded ‘store and forward’ video or image technology, including interpretation with verbal follow-up with the patient within 24 business hours.” Like the virtual check-in, this service could not originate from a related E/M service provided in the previous 7 days or lead to an E/M service in the next 24 hours.

Similar to the chronic care management benefit, RHCs will have a different billing mechanism than their fee-for-service peers. CMS is proposing to create a specific RHC G-code with a payment rate that is the average of the two new G-codes available on the fee-for-service side. CMS considered proposing paying for this “virtual check-in” via the all-inclusive-rate but opted for this “combined G-code” methodology instead because they felt that this service would not meet the requirements of an RHC billable visit. It is not yet clear how much that average payment will be.

While it may be reasonable to assume that the cost-reporting implications of providing this service are similar to how we handle care management services, CMS did not specify in this proposed rule those details. NARHC will be sure to work with CMS to get clarification on these new benefits before 2019.

Nathan Baugh

July 11, 2018
Palmetto Recoupment One-Month Filing Extension of “Improperly” Paid Claims

Yesterday (7/10) I expressed my disappointment that the most recent posting by Palmetto regarding challenges to the recoupment notices did not reflect an understanding we had reached with CMS last week. Specifically that RHCs would have until mid-August to file reconsideration notices for recoupments they felt were in error.

I communicated to CMS officials our disappointment with the posting and that it did not reflect what CMS said they would do.

Yesterday afternoon, I received an updated posting modifying the July 6th Palmetto posting that reflects what CMS said during our meeting on July 5th. This is the new posting:

07/10/2018: Postponement of Claim Cancellation/Recoupment: Providers who have exceptions they feel are warranted must at least start the exception process by submitting an INITIAL exception request no later than close of business on August 17, 2018. Receipt of an INITIAL exception request – with documentation – will result in a postponement of recoupment of ALL claims for which recoupment is sought until a determination is made of the legitimacy of the challenged claims. Even if you are unable to complete your review of ALL claims prior to July 16, recoupment will be stopped for ALL claims upon receipt of a valid INITIAL exception request. Palmetto GBA will begin the auto-cancellation of affected claims for providers who did not submit a valid INITIAL exception request on August 18, 2018.

This one-month extension (August 17th) of the date for filing an INITIAL exception request is consistent with what we discussed with CMS. I want to thank CMS leadership for providing this additional time for RHCs to review the claims for which recoupment is being sought.

What NARHC is continuing to do

NARHC continues to push CMS to direct the Medicare Advantage Plans to waive their timely filing requirements so that any claims that were paid by traditional Medicare but were actually the responsibility of the MA plan, can be submitted to the MA plan for processing and payment.

We’ve not received any recent updates on this and will pass along any information we receive as soon as it is available.

It has been estimated that the total amount in question – when you combine all of the provider-types affected (RHCs, hospitals, CAHS, SNFs and ESRD facilities) – is close to $60 Million.

If the MA plans are not required to waive timely filing and accept, process and pay these claims, this means that the MA Plans will have retained $60 Million in profits from money that should have gone to health care providers for medically necessary care the providers delivered to Medicare beneficiaries. All due to an error by a Medicare contractor.

NARHC will continue to push CMS on this important point.

What you can/should do over the next 30 days

If you have received a recoupment request, it is in your best interest to review ALL claims for which recoupment is being sought. NARHC is receiving reports from many RHCs that claims Palmetto is alleging were improperly paid had previously been identified by the RHC and any monies improperly paid for those claims had already been repaid to Medicare.

Submit a request for reconsideration as soon as you identify an error. You do not need to submit all challenges at the same time. You do not need to complete your review before submitting any challenges. However, you will have to provide some evidence to support your challenge.

By submitting a request for review – including the information you have supporting your challenge – Palmetto will suspend any recoupment efforts for your clinic until ALL claims/beneficiaries for whom review has been requested have been resolved.

Finally, let me know at how this process is going.

NARHC will continue to provide additional updates as information warrants.

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

Bill Finerfrock

July 10, 2018
Update on Palmetto Recoupment of “Improperly” Paid Claims

Last week I had a meeting with senior leaders at CMS to discuss the efforts by Palmetto to recoup monies they believe were improperly paid by Cahaba for Medicare beneficiaries enrolled in MA plans at the time the services were rendered. When that call ended, I believed we had an agreement to provide additional time to RHCs to review the information provided by Palmetto to determine the accuracy of the claims denials. Specifically, I believe we had an agreement to give RHCs until mid-August to review and submit challenges and that recoupment would be delayed until that time.Late yesterday I was given an update – put out by Palmetto – that does NOT reflect the agreement I felt had been reached between NARHC and CMS. I have already expressed my concern about the difference between what has been posted and what I felt we’d agreed to with CMS.

The following appears on the Palmetto website:

Status as of 7/6/2018: Postponement of Claim Cancellation/Recoupment: Providers who have exceptions they feel are warranted must at least start the exception process by submitting an INITIAL exception request no later than close of business on July 16, 2018. Receipt of an INITIAL exception request – with documentation – will result in a postponement of recoupment of ALL claims for which recoupment is sought until a determination is made of the legitimacy of the challenged claims. Even if you are unable to complete your review of ALL claims prior to July 16, recoupment will be stopped for ALL claims upon receipt of a valid INITIAL exception request. Palmetto GBA will begin the auto-cancellation of affected claims for providers who did not submit a valid INITIAL exception request on August 18, 2018.

Here are the links to review what is posted on the Palmetto website on this issue. I will say, however, that I find the information confusing and contradictory.

As noted, it was my understanding from my call with CMS that RHCs would be provided additional time to review the claims/beneficiaries in question and have until mid-August to submit their challenges. The above message states that requests for review must still be submitted by Monday (July 16) and only recoupment itself will be delayed until August 18th.

What you can/should do

First, if you received a recoupment notice from Palmetto and you believe that it has errors, you MUST submit a request for reconsideration as outlined in the above postings. You do not need to submit all challenges at the same time. You do not need to complete your review before submitting any challenges.

Second, As you find additional errors, submit those as well. By submitting a request for review – including the information you have supporting your challenge – Palmetto will suspend any recoupment efforts for your clinic until ALL claims/beneficiaries for whom review has been requested have been resolved.

Finally, let me know at how this process is going.

What NARHC is doing

I believe I made it clear that RHCs needed more time to properly review the individual situations where there might be potential questions about the validity of the Palmetto recoupment order. The Palmetto update does NOT provide any additional time for the review, it merely delays the date upon which recoupment will commence.

In addition, we also discussed the issue of timely filing of claims where there was agreement that the individual was enrolled in an MA Plan and that the MA Plans, not traditional Medicare, was responsible for paying the claims. CMS agreed to work with the plans to get timely filing waived.

If timely filing limits are not waived and Medicare successfully recoups these monies, the financial ramifications for RHCs and others (hospitals, CAHS, SNFs and ESRD Facilities) will be devastating. It is highly likely that many facilities will have to seek bankruptcy protection and in the most extreme cases, close their doors leaving entire communities with no healthcare providers.

To me, the greatest irony is that if timely filing is not waived, the MA Plans will be allowed to retain millions of dollars in revenue (i.e. profits) that rightfully should have been paid to RHCs, Hospitals, CAHs, SNFs and ESRD facilities for medically necessary care delivered to Medicare patients.

I will provide additional updates as information warrants.  Please do not hesitate to contact me if you have any questions.

Bill Finerfrock


July 3, 2018
Palmetto Recoupment Update

As you know from my previous posts, NARHC continues to work on the Palmetto recoupment problem.  To say that this is a mess would be an insult to anything I’ve previously described as “a mess.”

While I appreciate efforts by Palmetto to be responsive, the options they seem to have available for a fair resolution of this problem seem limited.  For this reason, we are taking this issue to the highest levels at CMS.

On Thursday, July 5th, I will be meeting with the Deputy Administrator of CMS for Operations (#2 person) to discuss this problem and pursue alternative means of resolution.  In particular, it is our belief that ultimately it is the Medicare Advantage plans that are liable for the payment of these claims.  Unfortunately, we know that most of these claims will be subject to payment denial by these plans due to “timely filing” requirements.  Failure to obtain recoupment of these monies from the Medicare Advantage Plans (either by the Clinics or CMS) means that MA Plans will have made millions in unearned profits as a result of this screw up by Cahaba.

We also believe RHCs will need more time to review the alleged improper payments and obtain the information necessary to properly challenge the assertion by Palmetto that the RHC received – and retained – monies improperly.

And speaking of time.  Many RHCs have asked about their appeal rights or opportunities to formally challenge the Palmetto allegations.  As we’ve previously noted, Palmetto has extended the effective date and provided an email address through which the RHC can submit information challenging their findings.  But for some, this may not be enough.  Particularly if you are an RHC that is facing a large recoupment.

Here is a link to a letter we obtained from a lawyer who works in this arena.  This letter is for EDUCATION ONLY and does not constitute legal advice.  As the letter notes, this firm has not been retained by NARHC.  The letter seeks to highlight the legal basis for the actions by Palmetto and possible avenues for resolution of this on a clinic level.


July 02, 2018
Palmetto Recoupment Educational Letter

For the past 10 days, NARHC has been communicating with officials from Palmetto and CMS regarding the recoupment letters sent to RHCs on June 15th.  NARHC has been notified by officials from Palmetto that the following message will be distributed to the RHC Community & posted on the Palmetto listserv.

Jurisdiction J (JJ) Medicare Advantage (MA) Overpayment Issue

Postponement of Claim Cancellation/Recoupment:  Palmetto GBA will extend the cancellation and recoupment date of these claims from July 1, 2018 to July 15, 2018, to allow providers additional time to research their patient account records and provide us with information to review and consider for exception.

Exception Requests:  This two-week extension will allow providers greater opportunity to research and submit instances where they believe they should receive an exception to the claim cancellation and recoupment process.  Valid exceptions might apply if the provider has already made payment through the Credit Balance Report, submitted payment in the form of a voluntary refund, or the provider can show that the Common Working File was updated to show the patient was NOT covered under an MA plan.

Submitting Exception Requests:  If you believe you have a valid exception request, you may send an email to notifying us and including the documentation of your claim (the following are examples and not exhaustive of all possible forms of appropriate documentation):

  • Copy of cancelled check
  • Credit Balance Report documentation showing the listing of claims you requested to have cancelled
  • Proof of delivery receipt to Cahaba GBA

In addition, Palmetto has created a Frequently Asked Questions document that should answer some of the additional questions you may have.   CLICK HERE for link.

NARHC would like to thank the staff at Palmetto for listening to the concerns raised by NARHC as well as many individual rural health clinics that contacted Palmetto directly.  While we view this as a slight improvement in the situation, this does not go as far as we think is necessary or appropriate.  It is important to keep in mind that this problem occurred because the previous Medicare Contractor failed to properly flag/return claims for beneficiaries enrolled in a Medicare Advantage plan.

It is our understanding that CMS provides a “hard” edit to each MAC that is supposed to catch & reject a claim when the beneficiary is enrolled in a Medicare Advantage plan.  This edit was either not working, installed improperly or never installed.  It should also be noted that this problem is not only affecting Rural Health Clinics previously serviced by Cahaba.  This problem is also affecting other providers whose claims were processed by Cahaba.

If you are an RHC in the Palmetto service area, please be sure to visit the Palmetto website or sign up to be on the Palmetto listserv.  This can be done by visiting the Palmetto website and click on the “listserv sign-up” icon.

P.S.  – The 180 day timeframe referred to in the letter applies to the review of claims the RHC should undertake beyond the 4 years where there may be a patient obligation issue.  Currently, Palmetto intends to commence recoupment of the claims they have identified based upon their 4-year look-back on July 15th unless the RHC files a request to review based upon credible information you have that Palmetto may have identified claims(s) in error.


June 22, 2018
Outpatient Services Incorrectly Paid

NARHC has been in contact with Palmetto regarding the letters sent to RHCs this month Re: “Outpatient Services Incorrectly Paid by Medicare for Beneficiaries under a Medicare Advantage Plan.”  Palmetto has informed us that additional communications are forthcoming on Monday, June 25th, which should address some of the concerns we have heard from the RHC community including:

-additional tools to identify the claims and patients affected
-instructions on how an RHC may challenge Palmetto’s ruling
an updated timeline

If you are one of the RHCs affected by this issue, please be on the lookout for additional information from Palmetto, Monday, June 25th. While, Palmetto will be putting this information out through their own channels, we are also planning to share the information on our listservs due to the number of RHCs that are affected.

NARHC plans to remain in communication with both Palmetto and CMS as this issue develops.

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


June 21, 2018
Palmetto Audio Notification

The following message is directed to those RHCs who for many years submitted their RHC claims to Cahaba.  This does NOT impact those RHCs who submit claims to other MACs.  However, RHCs who submit claims to other MACs may want to read this message as a cautionary tale to make sure something like does not happen to you.

Earlier this week, approximately 1,000 Rural Health Clinics who submit their RHC claims through Jurisdiction J began receiving letters from Palmetto indicating that they received improper payments (overpayments) from Cahaba (the previous MAC) for services provided between 2014 and 2018.  These overpayments supposedly occurred because the patients for whom these claims were submitted, were enrolled in a Medicare Advantage plan at the time the service was provided.

It appears that Cahaba (as Jurisdiction J MAC) failed to properly conduct a front-end edit of both Part A and Part B claims for several provider types, including RHCs. The result, according to Palmetto, is that thousands of claims were paid by traditional Medicare that should have been submitted to an MA Plan that was responsible for paying for the care of these Medicare beneficiaries.

Palmetto has identified thousands of improperly paid claims submitted by more than 1,000 RHCs in Jurisdiction J (nearly one quarter of all RHCs in the country).  They are seeking recoupment for these improperly submitted claims.

Please note that we’ve heard from several RHCs indicating that there are major errors in the Palmetto list of “improper” claims for which they are seeking recoupment.  There are claims that truly were appropriate for traditional Medicare or situations where the RHC itself had previously identified the improper payment and reimbursed the money and Palmetto does not seem to be aware of this resolution. 

At this time, we are unable to offer any solutions but we would encourage you to review all of the claims that Palmetto has identified as being paid in error.

For all of those RHCs affected by this mess, we want to assure you that NARHC has been in touch with CMS and Palmetto and we are looking at ways to resolve this mess.  Due to looming deadlines, we are pressing these officials to provide a solution sooner rather than later.  we can assure you that this is being reviewed at the highest levels of the Center for Medicare and Medicaid Services and we have impressed upon these officials that some RHCs will have to close because under “timely filing” limits, they will be unable to submit these claims to the MA plan for payment.  Many RHCs cannot afford that type of financial loss.

NARHC will continue to work with CMS and Palmetto to get this resolved.  Our goal is to ensure that no RHC has to close because of this and that there is a way for RHCs to either keep the money they’ve been paid or allow the RHCs to resubmit these claims to the MA plan (i.e. waive timely filing) so they can get paid by the proper payer for the care they provided.

As we get more information, we will post this on the listservs (both RHC TA and NARHC News).

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

June 19, 2018
Updates From Palmetto

We have been asked by Palmetto to share the following with the RHC Community.  If you are not in the Palmetto service area, you can disregard this posting.

There are three updates for RHCs that have been posted within the last few days/weeks.  If you are an RHC that submits your claims to Palmetto – particularly those who previously submitted claims to Cahaba – you are encouraged to review the RHC related posts appearing on this webpage:

Please note that Palmetto is requesting that providers – RHCs and others – refrain from calling the PCC for status on one of these outstanding issues.  Instead, it is highly recommended that you sign up for Palmetto email alerts available at the end of the CPIL.


April 19, 2018
2018 MIPS Eligibility Tool

The CMS has released it’s 2018 MIPS Participation Lookup Tool. You may use the updated Lookup Tool to check your eligibility in 2018 for the Merit-based Incentive Payment System (MIPS). Rural Health Clinic providers can enter their National Provider Identifier (NPI) to find out if they’re required to participate during the 2018 performance year.


March 29, 2018
New Medicare Card

Beginning in April 2018, the Centers for Medicare & Medicaid Services (CMS) will start mailing new Medicare cards to all people with Medicare.  The roll-out will occur over a several month period based upon the geographic location of the Medicare beneficiary.

You are encouraged to talk with your Medicare patients about this so they are aware of the transition and do not think that this is a “scam”.

  • Newly-eligible beneficiaries will get a card with a unique number, regardless of where they live
  • Distribution of cards will be randomized by geographic location
  • Starting in April, people with Medicare will be able to go to to sign up for emails about the card mailing and to check the card mailing status in their state
  • People with Medicare should use the new card once they get it, but either the SSN-based or the new random alphanumeric-based numbers can be used through December 2019
  • Beginning January 1, 2020 only the new card will be usable

Here is the state-by-state roll out schedule:

States/Regions Roll Out Time Window
Delaware, District of Columbia, Maryland, Pennsylvania, Virginia, West Virginia April – June 2018
Alaska, American Samoa, California, Guam, Hawaii, Northern Mariana Islands, Oregon April – June 2018
Arkansas, Illinois, Indiana, Iowa, Kansas, Minnesota, Nebraska, North Dakota, Oklahoma, South Dakota, Wisconsin After – June 2018
Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Rhode Island, Vermont April – June 2018
Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Rhode Island, Vermont After – June 2018
Alabama, Florida, Georgia, North Carolina, South Carolina After – June 2018
Arizona, Colorado, Idaho, Montana, Nevada, New Mexico, Texas, Utah, Washington, Wyoming After – June 2018
Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Puerto Rico, Tennessee, Virgin Islands After – June 2018


February 05, 2018
CMS Publishes AAPM Table (Advanced Alternative Payment Models)

Today, the Centers for Medicare and Medicaid Services (CMS) published a table displaying the Alternative Payment Models (APMs) that CMS operates. In the table CMS identifies which of those APMs CMS has determined to be MIPS APMs or Advanced APMs. We will modify this list based on changes in the designs of APMs or the announcement of new APMs.

See the table here:


February 02, 2018
State Operations Manual (SOM) Appendix G – (Guidance for Surveyors: Rural Health Clinics)

CMS recently released a new version of the State Operations Manual (SOM) Appendix G. You can find it at:

This document contains significantly more detailed interpretive guidelines for RHC survey and certification than the previous version. If you have questions on how to meet the RHC rules and regulations, this document will likely have the answers you seek.


January 24, 2018
National Advisory Committee on Rural Health and Human Services Recommendations

The National Advisory Committee on Rural Health and Human Services (NACRHHS), recently released their policy brief and recommendations on how to “Modernize Rural Health Clinic Provisions.”

The NACRHHS picks one or two issues a year and produces a policy brief(s) for the Secretary of HHS. Last year, the committee chose to focus on Rural Health Clinics and we believe they have produced a thoughtful report with several helpful recommendations including:

  • Raising the AIR cap on RHCs
  • Grants to State Offices of Rural Health to support value-based care
  • Allowing RHCs to be distant site telehealth providers
  • Modernizing lab requirements
  • Allowing masters trained behavioral health providers to be RHC practitioners
  • Allowing RHCs to contract with PAs or NPs to fulfill the 50% requirement

You can read the full report for yourself here:

We recommend sharing this report with healthcare leaders in your community. If we communicate these ideas to decision makers effectively we can improve the viability of the Rural Health Clinic program.


January 10, 2018
Laboratory Billing

Program Memo issued by CMS (at the time known as HCFA) which addresses laboratory billing by both independent and provider-based RHCs, states:

Laboratory In light of recent inquiries regarding laboratory services, we are clarifying whether diagnostic laboratory tests furnished in the RHC/FQHC by their personnel are covered RHC/FQHC services paid under the all-inclusive rate, or whether such services are beyond the scope of RHC/FQHC services. While the law requires a facility seeking to be certified by Medicare as an RHC to provide routine diagnostic services, clinical diagnostic laboratory services are not within the scope of services covered and paid for under the RHC provisions.

Consequently, laboratory services (including the six required laboratory tests for RHC certification at 42 CFR §491.9) furnished by a clinic should be paid under the laboratory fee schedules. When clinics separately bill laboratory services, the cost of associated space, equipment, supplies, facility overhead and personnel for these services must be adjusted out of RHC/FQHC cost report. Furthermore, freestanding clinics should bill laboratory services to the Part B carrier and provider based clinics should bill these services to the fiscal intermediary that serves the main provider (e.g., the hospital’s intermediary).

The effective date of January 1, 2001 should be applied to implement this pronouncement to avoid the administrative burden of retroactively adjusting claims and cost reports.


December 15, 2017
Essential Community Provider Designation

Are you an Essential Community Provider (ECP)? Most Rural Health Clinics will answer that question with a resounding YES! But for many Health Plans sold on the Affordable Care Act (ACA) Exchanges, the answer is often a resounding “maybe”. Why, because many RHCs have failed to petition for ECP designation.

Under the ACA, RHCs are eligible for designation as Essential Community Providers which would enhance or strengthen the likelihood that Health Plans would be required to include your clinic in their provider networks under the “Network Adequacy” standards. But ECP designation is not automatic. Here is a link to the DRAFT ECP list released recently by the Centers for Medicare and Medicaid Services (CMS).

RHCs are one of the largest groups of provider types on the DRAFT ECP list but we know that many RHCs are not on this list. Please take a few minutes to see if your RHC is on this list (you can search by clinic name. If you are not on the list, go to the CMS website and complete the petition to be added to the list. It only takes a few minutes to get your clinic listed and the benefits of this could be significant when Health Plans begin putting together their provider networks in 2019.

NOTE: The deadline for submitting an ECP petition is December 22, 2017

If you have any questions or need additional information, you can submit those to:
Some facilities qualify in multiple categories. For example, a facility might choose as their primary “Black Lung Clinic” but also qualify as an “RHC” as a secondary designation.


November 20, 2017
RHCs Serviced by Cahaba

As you should have heard, Cahaba has lost their contract as a Medicare Administrative Contractor (MAC) for Jurisdiction J (JJ) (Alabama, Georgia, Tennessee). The new contractor for MAC Region J (JJ) will be Palmetto GBA.

Jurisdiction J (JJ), in addition to handling Medicare Part A and B claims for the three states mentioned above, was also the “legacy” MAC for hundreds of RHCs located outside of Jurisdiction J (JJ). Below is a link to an FAQ document produced by Palmetto GBA intended to answer questions from providers (hospitals, physicians, RHCs, etc.) affected by this change.

You are encouraged to review the entire document; however, there are two questions of specific interest to the RHC community that I have reproduced here:

Questions: I am with a RHC in Illinois, currently Jurisdiction J (JJ), submitting to Cahaba. Will we be included in the 01/28/18 transition date?
Answer: Yes, any current Jurisdiction J (JJ) providers with Cahaba GBA will transition to Palmetto GBA.

Question: Since Rural Health Clinics (RHCs) submit two claims, one to Part A on the UB04 claim form and one to Part B in the 1500 claim form, how will we submit our claims since Part A transitions in January and Part B transitions in February?
Answer: To submit claims for an RHC visit after Part A has transitioned to Palmetto GBA but Part B has not, you will submit the Part A claim to Palmetto GBA and the Part B claim will still be submitted to Cahaba GBA for processing.

If you are affected by this change and you have questions, you are encouraged to reach out directly to Palmetto GBA staff.

To download the Palmetto GBA Provider Outreach & Education Speaker Request Form click here.


November 2, 2017
Emergency Preparedness

November 15th is fast approaching and all RHCs must have taken steps to be in compliance with the new Emergency Preparedness requirements CMS will begin enforcing on that date.  NARHC is offering a free Technical Assistance call on the topic on 11/2/17.  We will review the new RHC Emergency Preparedness Conditions, the expectations for the RHC community and what you should be doing to be in compliance with the new requirements.  If you missed it we will have a recording available in about a week. CLICK HERE for a link to the page.


June 27, 2017
MACRA Proposed Rule for 2018
Last week, CMS released their 1,050 page MACRA proposed rule for calendar year 2018.

The big proposed change is an increase in the low-volume threshold for participation in MIPS to $90,000 (up from $30,000) of Medicare allowable revenue or 200 (up from 100) Medicare part B patients. This proposed change should exempt most RHC clinicians from the MIPS program.


As a refresher, MACRA stands for the Medicare Access and CHIP Reauthorization Act of 2015 and it is the underlying law behind the Quality Payment Program (QPP) which establishes two new payment tracks for eligible clinicians: the Merit Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APMs). These new payment systems are designed to reward eligible clinicians (physicians, PAs and NPs) for the value of their care.

MIPS rewards clinicians who achieve high (CPS) Composite Performance Scores with bonus payments, and penalizes clinicians with poor CPS scores.

RHC payments are exempt from MIPS because the program only affects payments made under the Medicare Physician Fee Schedule (PFS). As you know, RHCs are paid on a cost basis through the RHC All-Inclusive Rate and bill on a UB-04 form. However, many RHCs bill for so-called “non-RHC services” on a CMS-1500 to a Medicare Part B MAC. These claims are potentially subject to MIPS payment adjustments if a clinician has enough “PFS” revenue/patients. However, CMS is now proposing a higher low-volume threshold that would exempt most clinicians and almost all RHC practitioners from participation in MIPS.

Clinicians can participate in MIPS individually, as a group (if the eligible clinician belongs to a group), or as a virtual group (individuals or several groups joining together for the purposes of a MIPS CPS score). Applicability of the low-volume threshold depends on the reporting entity. For example:

Consider three clinicians in a group practice. Each clinician has $50,000 of Medicare allowable revenue. If CMS finalizes the low-volume threshold as proposed, the clinicians would be exempt from MIPS in 2018 if they report individually. However, if they report as a group, they would all be eligible for a MIPS CPS score because, together, they have $150,000 of total allowable Medicare revenue.


One other way to avoid MIPS adjustments, is to participate in an Advanced APM. These are payment models that incorporate EHR standards, quality metrics, and have some financial risk to the provider. Clinicians who participate in an Advanced APM receive a lump sum incentive payment of 5% based on their PFS revenue. Any revenue generated through an RHC (or UB-04) claim, would not count towards this lump sum bonus.

The arrangements and details of each Advanced APM are too complicated for the purposes of this email. However, you may research more about Advanced APMs here.


The proposed rule is open for public comment until July 23rd. Once the public comment period ends, CMS will review all comments and potentially make changes in the proposal prior to the issuance of the final rule. CMS expects to issue the final rule in early November.

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


June 14, 2017
NARHC Website has New Look + Increased SSL Security

The NARHC Website has a new look & feel plus additional SSL security!  We hope you like it!


June 13, 2017
RHC Guidelines & Emergency Preparedness

Please note that the RHC Guidelines & The Emergency Preparedness have undergone some recent changes. Check them out on our website on this link:


CLICK HERE for ARCHIVES (posts prior to June, 2017)