Arizona Rural Health Clinic Designation Manual - Arizona Center for ...

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D. Frequently Asked Questions Q: What are the benefits of being certified as a RHC A: RHCs receive enhanced Medicare and Medicaid reimbursement. Medicare visits are reimbursed based on allowable costs and Medicaid visits are reimbursed under the cost-based Prospective Payment System (PPS). Since certified RHCs are reimbursed on a cost-based reimbursement, as opposed to a fee-for-service reimbursement, RHC certification can increase revenues. RHCs may see improved patient flow through the utilization of NPs, PAs and CNMs, as well as more efficient clinic operations. Q: How do I know if becoming certified as a RHC could be financially beneficial for my clinic A: Experts say that a good rule of thumb to follow is if at least thirty-five to forty percent of your patients are combined Medicare and Medicaid patients, then becoming a certified RHC could be financially beneficial to your clinic. Q: How does a certified RHC differ from a Federally Qualified Health Center (FQHC) A: Federally Qualified Health Centers are organizations that receive grants under section 330 of the Public Health Service Act. FQHCs must be open at least 32 hours per week, whereas RHCs have no minimum hours per week requirement. In addition, a for-profit clinic cannot be a FQHC but can be certified as an RHC. Unlike RHCs, FQHCs must be governed by a board of directors. FQHCs are required to provide mental health and substance abuse services, dental services, transportation services required for sufficient patient care, hospital and specialty care; RHCs are not required to provide these services. Q: Do I need a separate building to have an RHC A: No. An RHC can be in a stand-alone building, a part of another building or a mobile unit. Q: What types of services do RHCs provide A: RHCs must provide outpatient primary care services and basic laboratory services. They can also offer other services such as mental health services and vision services, however, such services may not be reimbursed based on allowable costs. Q: If a location loses its shortage designation, is it possible to remain a Rural Health Clinic A: Rural Health Clinics located in rural areas that are no longer designated as medically underserved may apply for an exception. Proposed criteria for allowing an exception are spelled out in the Federal Register notice Medicare Program; Rural Health Clinics: Amendments to Participation Requirements and Payment Provisions; and Establishment of a Quality Assessment and Performance Improvement Program; Final Rule (see section II.C. Important Update from the National Rural Health Clinic Association regarding the details and status of this CMS Final Rule). Q: Are there special staffing requirements for RHCs A: RHCs must employ at least one nurse practitioner (NP), physician assistant (PA), or certified nurse midwife (CNM). The NP, PA, or CNM must be on-site and available to see patients at least 50% of the time the clinic is open. RHCs must have a physician present on-site and available to see patients at least one day every two weeks, unless greater on-site availability is required by state 10
D. Frequently Asked Questions (con’t) law or state regulatory mechanism governing PA, NP or CNM practice. Q: What is the per visit upper payment limit for RHCs for 2008 A: For CY 2008, the Medicare RHC upper payment limit per visit is $75.63. Provider-based clinics that are owned by a hospital with less than 50 beds are exempt from this per visit reimbursement cap. For more information, visit the Centers for Medicare and Medicaid Services at: www. cms.hhs.gov . Q: How does Medicare reimburse RHCs A: Certified Rural Health Clinics receive an interim payment rate throughout the clinic’s fiscal year, which is reconciled at the end of the fiscal year through cost reporting. The interim payment rate is determined by taking total allowable costs for RHC services divided by allowable visits provided to RHC patients receiving core RHC services. RHC staff should understand traditional Medicare regulations for coding and documentation as well as unique RHC billing requirements. Q: How does Arizona reimburse RHCs for Medicaid A: AHCCCS, Arizona’s Medicaid program, recognizes RHC services. The state reimburses RHCs under one of two different methodologies. The first is a prospective payment system. Under this methodology, for fiscal year 2001, the state calculated a per encounter rate based on an average of 100 percent of the reasonable costs furnished in FY 1999 and FY 2000. For each succeeding year, this per encounter baseline rate is then increased by the Medicare Economic Index factor. The second rate setting methodology (the Alternative Payment Methodology) requires a rebase of the PPS rate every three years, and the physician services component of the CPI is used to inflate the rate during the interim years. The clinic must agree to this methodology, and the payment to the clinic must at least equal the payment under a prospective payment system. The Arizona reimbursement methodology can be downloaded at: http://www.azahcccs.gov/PlansProviders/FQHC_RHC/FQHC_RHC.asp Q: How is an RHC encounter defined A: An encounter is defined as a face-to to-face visit between a recognized provider (i.e., physician, PA, NP, CNM, or mental health provider) and a Medicare beneficiary for a medically necessary reason. Clinics receive the RHC rate for Medicare patients for every encounter. Q: What is the difference between a UPIN and a PIN A UPIN (Unique Provider Identification Number) is a six-character alphanumeric identifier assigned to all Medicare physicians, medical groups and non-physician practitioners. A PIN (Provider Identification Number) is a unique number issued by payers to each provider to identify that provider as a credentialed and approved provider. This number is also known as a Medicare billing number. 11
Page 1 and 2: Arizona Rural Health Clinic Designa
Page 3 and 4: Community Environment & Policy 1295
Page 5 and 6: A. Background Information (con’t)
Page 7 and 8: B. Rural Health Clinics in Arizona
Page 9: C. Number of Rural Health Clinics i
Page 13 and 14: D. Frequently Asked Questions (con
Page 15 and 16: E. Steps to Becoming a Certified Ru
Page 17 and 18: B. Interpretive Guidelines for Rura
Page 29 and 30: D. Preparing for the Certification
Page 37 and 38: 30 Most Common RHC Survey/Certifica
Page 39 and 40: F. RHC Cost Report The Medicare cos
Page 41 and 42: F. RHC Cost Report (con’t) •Wor
Page 43 and 44: F. RHC Cost Report (con’t) 11) Li
Page 45 and 46: G. Important Resources (con’t) -A
Page 47 and 48: Appendix A. Important Contact Infor
Page 49 and 50: Appendix B. Definitions for Rural H
Page 51 and 52: Appendix C. Federal Primary Care HP
Page 53 and 54: Appendix • C. Federal Primary Car
Page 55 and 56: Appendix D. Federal MUAs in Arizona
Page 57 and 58: Instructions for completing HCI App
Page 59 and 60: A. PLEASE LIST IN THE SPACE PROVIDE
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MEDICAL FACILITIES LICENSING 150 N.
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ARIZONA DEPARTMENT OF HEALTH SERVIC
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MEDICAL FACILITIES LICENSING 150 N.
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http://www.azdhs.gov/als/forms/otcs
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Appendix F. Certification Forms 1.
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3. Has successfully completed a for
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DEPARTMENT OF HEALTH AND HUMAN SERV
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DEPARTMENT OF HEALTH AND HUMAN SERV
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According to the Paperwork Reductio
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MEDICARE ENROLLMENT APPLICATION INS
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2990 (Cont.) Form CMS 222-92 03-02
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RURAL HEALTH CLINIC SURVEY REPORT F
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NAME CODE YES NO N/A EXPLANATORY ST
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