CHC leaders are some of the most passionate and driven workers I have ever come across. Their dedication to the patients that they serve is truly admirable. As a Revenue Cycle professional, I have a tendency to focus solely on the money but that does not stem from a lack of human compassion, quite the opposite is in fact true. Some time ago a phrase was coined here at PMG and it rings even truer in today's uncertain fiscal climate: "CHCs need to get paid as much as they can whenever possible so they can afford to give away services when they want or need to." Your patients and community, especially those unable to pay for services, depend on you to get paid as much as you can from Medicare and other payers so when a need arises you have the money to fill the need.
In my career, I have visited and/or trained thousands of staff from hundreds of CHCs representing all fifty states and U.S. territories. In all that time I have never met a CHC leader who has worried about having too much revenue. That is why I am continually amazed at how many CHCs make an overt decision to not bill Medicare. That's right, to not bill Medicare at all! Some centers feel it is just too complicated, others are lacking adequate staff, and some choose to focus solely on Medicaid. On the other side of the coin are centers who do bill Medicare, struggle to do it correctly, and lose revenue in the process.
We know that Medicare billing is rife with common but avoidable mistakes. In the spirit of Holiday giving, we present to you five elements of Medicare compensation which every CHC revenue cycle (billing) department should know.
"G" code pricing
The prospective payment system (PPS) "G" code rates continue to amaze. The 2017 ceiling for Medicare PPS is $163.49. Thanks to the 34% new patient bump, it is a whopping $219.34. However, if your CHC has not worked to make certain Medicare "G" code charges are at least close to or preferably exceeding these phenomenal rates, your CHC misses out. Remember under the current Medicare PPS, CHCs get paid the lessor... yes, the lessor... of their charge or the PPS "G" code ceiling. Also, CHCs payments are impacted by geographical adjustment factors (GAF) meaning your CHC may get slightly more or less of the above 2017 rates depending on your physical location. Regardless, for many CHCs, the Medicare PPS rate exceeds Medicaid PPS. The payment opportunity is enormous. Remember there is no mandatory methodology for determining "G" code charges. Certainly, you must (if asked) be able to explain how you arrived at rates BUT CHCs owe it to themselves and their fiscal health to make time to maximize charges to optimize potential payments. Finally, remember all charges (according to the FQHC Compliance Manual) must be regularly (think annually) affirmed/reviewed by your board or finance committee.
Expanding patient population
It is no secret that our country’s elderly population is living longer than ever and therefore Medicare enrolment is dramatically expanding. What is your CHC’s plan to grow its Medicare population? How about outreach to adult day care and senior centers, publicly held/promoted community health education program for seniors, a mobile van to bring isolated or less mobile Medicare patients to your CHC? Be creative. Find ways to get more Medicare patients into your CHC so you can become the “go to” location for seniors seeking healthcare. And, don’t forget your supplemental security income (SSI) patients who are often dually eligible. The only thing better than maximizing payment from a Medicare enrollee is maximizing payment from a dually eligible (Medi-Medi) patient as both Medicare and Medicaid PPS money is accessible for a single patient encounter.
Medicare Advantage FFS vs. PPS
Does your RCM/billing team understand the nuanced difference when your CHC is paid by Medicare Advantage (MA) vs. Medicare PPS? The number of questions on just this subject could fill a substantial Q&A document. Remember that MA is fee-for-service (FFS) which means ALL services (not just “core provider” work by docs, NPs, PAs, etc.) may be reimbursable. For instance, a nurse visit normally ineligible for Medicare PPS would now be eligible for payment via a 99211. All evaluation and management coding (e.g., 99201-99205 and 99211-99215) may be paid varying rates depending on the level of service (i.e., more money for higher level and less for lower). All those immunization and other ancillary services, typically held until submitting a PPS Medicare claim for a future “core provider” service are all potential FFS payment opportunities. Of course, some CHCs are savvy enough to have the MA (and sometimes even Managed Medicaid) plans pay a PPS rate. If that is the case, make certain you know if they allow billing/payment for non-core provider services often rendered by nurses, medical assistants, and other ancillary staff. A good general rule to follow is if you are paid the PPS rate, assume they only reimburse for face-to-face encounters with core providers just like nearly all straight Medicaid and all Medicare payers.
Medicare Advantage (MA) Wrap
If your CHC works with Medicare Advantage (MA) plans, make certain you are maximizing your Medicare wrap. MA Wrap payments are distinct from Medicare as Secondary Payer (MSP) payments. MSP occurs when Medicare is billed secondary to a commercial insurance (e.g., patient or spouse has coverage from working or a retiree benefit). For MSP, you must submit to Medicare the explanation of benefits (EOB) from the primary payer along with another bill with claim detail. (NOTE: Remember, straight Medicaid is always the payer of last resort.) What’s special about MA wrap payment is a CHC does not have to wait for a primary payer to make payment and send an EOB. You simultaneously bill the MA plan and your Medicare Administrative Contractor (MAC). Also important to remember is that your CHC must have an actual contract with an MA plan for those visits to be MA Wrap eligible. To be MA Wrap eligible your CHC is required to submit all MA contracts to your MAC. The MAC uses the contract terms to determine a single, standing “wrap” payment amount. Your CHC gets this same amount for every MA Wrap payment vs. differing amounts with MSP as it is an individual claim determination. Again, unlike most secondary payments for which you must wait for primary plan/payer payment, there is no waiting for the secondary payment. Your CHC is afforded revenue maximization from two payers after a single patient visit.
New patient definition
Confusion reigns around the Medicare PPS “G” code definition of “new” vs. established patients simply because it flies in the face of what every other payer and coding professional uses as the industry standard definition derived from the Current Professional Terminology (CPT) text. In short, the CPT definition says a "new" patient is one who has not for the last three years been seen by a provider of the same specialty within a group practice (i.e., same tax ID/EIN). So, if I grew up in a CHC and started with a pediatric doc, moved to a family practice provider in my late teens, and during my patient tenure sought care from a CHC employed podiatrist and LCSW, each of these providers could (by CPT definition) bill me as a "new" patient due to their unique board certification. Under the Medicare PPS “G” codes definition a "new" patient is one who has not been seen by any CHC professional within the last three years. Using my above example, as long as I did not avoid CHC care for more than three years, I would only be "new" at my initial encounter. The challenge for all CHCs is teaching staff to use the standard CPT definition while not missing the boat on the incredibly elevated Medicare "new" patient “G” code rate.
I truly hope you will find this useful at your own CHC. As we know, every dollar matters to your patient population and with perseverance Medicare billing can be the gift that keeps on giving. Wishing all in the CHC world a happy and safe Holiday season!
To many in CHC leadership, these three topics can be confusing. To maximize reimbursement, while staying compliant with governmental regulations and payer contractual language, it behooves CHC fiscal and RCM (revenue cycle management, a.k.a., billing) team leaders to peruse this article for a brief overview.
Before we even begin to delineate definitions of terms here is a quick review of NPI obtainment and why it happens. The National Plan & Provider Enrollment System (NPPES), is the entity responsible for the assignment of a unique "national provider identifier" or NPI. Remember that the1996 Health Insurance Portability and Accountability Act (HIPAA) mandated there be a single provider identifier to be used by all payers. Prior to HIPAA each payer had their own unique provider identifiers. In other words, if a doctor was a participating/credentialed provider with 10 health plans or payers, s/he would have 10 unique provider identifiers. Have just ten doctors in a practice, participating in the same or often different payers, and you have more than a hundred provider identifiers to track/manage. Just keeping track of all the numbers was maddening, never mind for each payer understanding or maintaining active status.
So, with HIPAA and via NPPES, each provider (and for CHCs typically each facility) must obtain a unique NPI. This NPI will follow individual providers (i.e., docs, NPs, PAs, CNMs, etc.) for the entirety of their career. Certainly, this was done to mitigate fraud by limiting the number of active provider numbers in the marketplace but also to allow payers as well as state and federal government to track providers, especially problem providers.
Simply stated, this is the process of getting a facility or individual provider NPI to be "active" or "participating" with a third party payer. Each payer is unique and while some (often many) use the same or similar application and/or process, each requires an NPI be uniquely "enrolled" to obtain "par" (short for participating) status. Most times when a CHC or a company says they do "credentialing" they really are moving through the enrollment or payer application process. Making payer application is entirely different from the vetting and approval process that really is credentialing.
As stated, enrollment is the making of an application while credentialing is the actual vetting process to determine whether a provider is worthy of "participation" or "par" status. Initially, the most basic demonstration of qualifications is necessary. These include but are not limited to:
Some payers want these data conveyed electronically while many still require a paper process. Regardless, providers or their authorized representatives must make attestation regarding any malpractice and/or other incidents related to professional service and answer a myriad of probing questions. After all these data are gathered, the payer/plan credentialing team perform "primary source verification" which means they verify submitted info by contacting medical/graduate schools and residency/training programs to confirm dates and degree status, they research DEA or state license status and any accusations or instances of malpractice, and generally make certain the data submitted is in fact an accurate and complete picture of the applicant's educational and professional history.
For Medicare and Medicaid, these payers also make certain the applicant is not in default status on student loans... a violation which will disallow their "par" status with any governmental payer and make it illegal for CHCs to obtain Medicare/Medicaid payment for work performed by these fiscally delinquent providers. Remember this includes Medicare Advantage and any managed Medicaid programs as well since these are funded by governmental dollars.
Once the application is deemed "complete" the provider/facility is presented to the payers'/plans' Credentialing Committee at which "par" status is granted or withheld. These committees often meet only monthly so missing information or delayed response to payer inquiry can push credentialing decisions back often at least a month... another month of that provider seeing patients for free.
These costly delays are all too common unless a CHC enrollment team is truly on the ball and understands exactly what is needed for each payer and by what deadline. This is not easy stuff nor is expeditious credentialing commonplace. Delays occur largely because this enrollment and credentialing oversight is typically "part-time" work for a CHC employee with other primary work responsibilities.
Facility (e.g., Hospital) Privileges
Like payer/plan credentialing, facilities (e.g., nursing homes or hospitals) require a vetting before allowing providers to see or treat patients at their facilities. They require basic applications with the requisite data already mentioned above in the credentialing overview. Like payers, they have a regular (often monthly) leadership meetings (sometimes multiple) during which applications are approved or denied. They also will determine what procedures/diagnostics the requested privileges will allow as well access to which departments/floors/services the provider will have. This is usually based on state scope of practice and unique training/certification held by the applicant.
For many CHCs, facility privileging can be a bit foreign if only because hospitalists are the norm. For those not familiar, hospitalists are groups of providers whose only function is to manage patients in a facility setting. Most often hospitalists have no private practice (are not CHC employees) and only see patients of other private providers when those patients are admitted to a facility. If your CHC covers a rural marketplace or struggles to engage a group of hospitalists to manage your CHC patients when they need to be admitted to a hospital, nursing home rehab center, etc., your CHC must understand the process and minimum requirements to obtain and maintain active facility privilege status.
While it is not hard to understand these three distinct terms and how they relate to your CHC, maximizing the process and fiscal opportunity is. Too many CHCs see significant denials or delayed payments because:
CHC mastery of credentialing/enrollment is quite difficult not because it cannot be learned but because it is so episodic. It is difficult to maintain skills when they are used so intermittently. So, two choices exist, allocate money and resources to maintain a true in-house expert or hire outside help from a firm who does enrollment/credentialing all the time. The latter is often incredibly cost effective and allows your CHC to focus on what it does best... bringing down barriers to care for those community members (i.e., patients) who need your CHC services.
Congressional consternation continues in Washington D.C. Too many options from too many interest groups makes it difficult to find commonality to meet the needs of all Americans. Perhaps that is the Achilles' Heel; i.e., no one plan will meet the needs of all. In the end, the most at risk populations... the poor, marginalized, and those in healthcare provider shorter areas (HPSA)... remain the most likely yet avoidable casualties of any sweeping reform beyond the Affordable Care Act (ACA).
Community health centers (CHCs; e.g., Federally Qualified Health Centers (FQHC), CHC Look-a-likes, etc.) are the one area of healthcare delivery on which both Republicans and Democrats should find common ground. The 1,200 CHCs afford access at more than 10,000 clinics and mobile units literally from Florida to Alaska... even the island Territories. The goal of all elected officials should be to sustain CHCs so they remain the viable backbone of the nation's healthcare safety net.
Make no mistake, these are non-profit entities working on low single digit margins. Sustaining a viable reimbursement system is critical for their survival. The prospective payment system (PPS) methodology is a unique staple of CHC compensation. This fixed but heavily regulated1 PPS payment from Medicare and Medicaid allow CHCs to see Medicaid patients when other doctors (due to anemic Medicaid fee-for-service payment) can ill-afford to do so. Private practices keep Medicaid patients at 7-11.5%2 of all visits while CHCs patients represent 51%. It is an economic reality that Medicaid fee-for-service cannot sustain a business. Ask any private practice administrator and they will tell you, available schedule slots for Medicaid patients are intentionally kept to a minimum.
Why sustain fiscal viability of CHCs:
Leaders should assure the Medicaid PPS annual rate of increase is controlled. Political leadership could follow Medicare's CHC PPS payment in which a singular "ceiling" of payment fluctuates based on a Geographic Adjustment Factor (GAF); i.e., more expensive regions get elevated payments, less expensive geographic areas see a downward adjustment. An annual escalator could follow CMS, the Medical Economic Index (MEI), or the FQHC Market Basket defined in the ACA.
To cover services beyond those offered at a CHC, a "major medical" high deductible health plan (HDHP) could be offered by state Medicaid programs with fees slid based on the Federal Poverty Guidelines. Like term-life insurance, this is the least expensive form of insurance but would, in the event of a medical emergency, afford financially disadvantaged patients the ability to have some coverage vs. going entirely without.
In the end, CHCs have been caring for the uninsured and underinsured, as well as undocumented patients, long before the ACA took effect. Action by local and national leadership is necessary to avert per capita or block grant subsidies from destabilizing these "essential care providers" who each day manage the mission critical work of caring for our nation's most vulnerable people.
1 CHCs are monitored/audited by the Bureau of Primary Health Care (BPHC) and the Health Resources & Services Administration (HRSA) never mind CMS scrutiny via claim analytics.
2 http://www.mgma.com/Libraries/Assets/Key-Findings-CostSurvey-FINAL.pdf?source; Slide 4
3 https://bphc.hrsa.gov/uds/datacenter.aspx?q=tall&year=2015&state=; Table 3A, Line 39
Too many CHCs are befuddled when it comes to understanding how to bill services under another provider's National Provider Identifier (NPI). Some CHCs do it every day, others never, and some sporadically while applying different rules or policies often founded in folklore or fantasy vs. payer contract language or government statute. Let's set the record straight on these terms, what they mean, and how to use them.
By definition from www.Merriam-Webster.com, locum tenens means "one filling an office for a time or temporarily taking the place of another —used especially of a doctor or clergyman." CMS provides an entire policy1 around locum tenens discussing "reassignment" of payments. The following excerpts are relevant for this conversation:
This is the only explicit federal policy regarding locum tenens AND it only applies to Medicare Part B payments. Why is this significant for CHCs? Several thoughts:
CHCs are paid via ANSI 837-I which is a Part A (not B) claim format/process. Funding is from Part B but Part A NPI rules apply.
Part A (837-I) pays the NPI of the facility, not the rendering provider NPI. The only CHC obligation in terms of the rendering provider is to make certain s/he is employed or contracted W-2 or 1099.
This is not a Medicaid policy… Locum Tenens only applies to Medicare Part B. For CHCs this means only ANSI 837-P claims billed for diagnostics and/or professional services at facilities such as hospitals, assisted living centers, and nursing homes.
Reiterating item 3 immediately above, there is no “standing” Locum Tenens policy. Each CHC must check with their state Medicaid program for written statute/policy and evaluate contracts in place for each managed care payer. Too many CHCs continue to think they can just hire a doctor, NP, PA, etc. and bill their work to all payers under any other provider’s NPI. They tell me they are “billing locums” as if this was some standing policy on which all payers agree. Again, no such thing exists. Sometimes when I suggest this is a risky practice they correct me and say they only use the medical director’s NPI… as if this would make it permissible. It does not.
“Incident to” Billing
If not “locums” another term misunderstood by CHCs is “incident to” billing. In short, “incident to” is often used to describe a provider (or ancillary staff person) without a billable NPI rendering services to be billed under another provider who has a billable NPI. Frankly, in conversation with too many CHC staff and leadership, it is often confused with locum tenens.
CMS has had formal policy regarding “incident to” billing since 1994. The Medicare Claims Processing Manual (MCPM) Chapter 122 has specific statutory language around “incident to” billing. It is worthwhile reading for any billing professional. Here is a synopsis of most relevant sections:
While these statutes are enlightening, please remember:
So, like locum tenens, since this is a Medicare only policy a CHC must know “incident to” rules existing for state Medicaid statute and managed care payer contracts. There is no “standard” way to interpret “incident to” rules. Every managed care and state Medicaid payer is different.
FQHC Manual & “Incident to” Billing
CHC staff will often convey that the FQHC manual allows “incident to” billing. These folks are referring to the Medicare Benefit Processing Manual (MBPM) Chapter 133 . The following bullets are relevant MBPM sections:
To summarize, “incident to” services at a CHC are covered BUT a CHC may only be paid the PPS rate when there is a medically necessary, face-to-face encounter between a Medicare beneficiary and a CHC core provider.
Make no mistake, locum tenens and “incident to” billing can cause confusion. Here’s a quick summary to hopefully make it easier to understand:
At PMG, when we are asked by CHCs to bill incident-to, under a locum, or to use a “supervising” providers NPI, what we are really being asked is “May I borrow that other provider’s number?” The answer should always be another two questions:
“What problem are you trying to solve by borrowing the number?”
The answer to the second question often makes it clear that they are just looking for ways to work outside the norm… and just to get paid. This would again move us down the line towards an abusive coding practice which is desirably avoidable.
The bottom line… know the rules! Audit records to make certain your team is doing things the right way. Never compromise just to get paid. Remember, ignorance of the rules never mitigates personal or CHC liability. Outsource enrollment and credentialing to an expert firm if you cannot garner enough expertise to both stay out of trouble and maximize payments from third parties. The peace of mind derived from doing things the correctly always wins over worry regarding questionable and risky business practices.
Coding is a complex topic. So confusing is it that too many in CHC leadership fail to sometimes grasp nuances essential to broadly capturing the full breadth and scope of all services rendered. This misstep results in undervaluation of actual services rendered, diminishes staff morale due to their inability to demonstrate the volume and intensity of work done, and (most obviously) mitigates full payment opportunities.
The transition to the Medicare's PPS G codes moved CHCs from a historic "cost based" reimbursement model to a "prospective payment system." For those not familiar, following is quick list of these codes:
As a taxpayer and businessman, the transition was to me sensible for two primary reasons:
The cost based system afforded a perverse incentive for CHCs to spend as much as possible on as few visits as possible to maximize their "cost per visit."
Medicare historically paid FQHCs at the encounter rate (actually, 80% of medical and 100% for preventive post ACA) even if charges were below the rate. This contradicted the industry standard of payers paying the lesser of a provider's charges or the payer's fee schedule.
The new PPS G code structure pays a fixed rate based on a CHCs fixed G code charges. CHCs must determine their average cost for each of the above and set a rate for their G codes. Thereafter, for a "qualifying visit1" a CHC is paid the lesser of the G code charge or the PPS ceiling (i.e., for 2016, $160.60.) This is good for taxpayers and federal fiscal fiduciaries but a challenge for CHCs struggling to calculate G code charges and understand which services fall under each unique G code.
To make this more complex Medicare limited G code payment to clinic scenarios represented by a finite range of HCPCS (e.g., "CPT") codes which must be justified for PPS payment to occur2. From the initial release of this list, coding professionals have bemoaned the limited range of HCPCS codes. Below are the top reasons why this must be rectified:
How can CMS compel CHCs to charge a Medicare patient cash for a service covered in any other setting?
At this moment in time, CHCs should be writing congressman and senators while asking patients to do the same. Certainly the omission of these codes was simply an oversight. However, the unintended negative consequences are dramatic, far-reaching, and discriminatory. Let's hope some collective "calls to action" can result in rapid rectification of this avoidable aberration.
Many CHCs struggle to maximize reimbursement. Transition from cost based to PPS rates, understanding Medicare G codes, ACA programs advocating APM and expansion of services via managed Medicaid plans... the complexities of healthcare, especially for CHCS, seems inexhaustible. Getting paid starts with having a National Provider Identifier (NPI) for all appropriate persons and entities. Most CHC billers and some CFO folks understand needing a facility NPI for each location and individual NPIs for core providers. However, too few understand potential pitfalls and too many think certain "common" practices are permissible when they are fraught with potential liability.
Here are a few quick thoughts to consider around credentialing... or more aptly, enrollment.
Call it enrollment or credentialing but this stuff can be vexing. Hiring an outside firm to manage enrollment/credentialing may seem like a luxury. In truth, the peace of mind for getting it done right (never mind an objective third party to vet internal processes) is priceless. Plus the ROI for the price of enrollment/credentialing service is usually equal to 10-12 paid visits for the newly enrolled/credentialed provider. In other words, national UDS data shows CHCs make about $125 per visit. Only 10-12 visits paid equals $1,250-$1,500. In other words, a service costing around this much money, pays for itself within 10-12 visits.
Regardless of the cost-effective services available, we expect too many "pennywise and pound foolish" CHC leaders will continue to find themselves behind the eight ball when an investigation or accusation arises around credentialing/enrollment. Avoid penalties, maximize income, and know your CHC does it right by vetting the processes internally or hiring an outside firm to assure optimal performance and compliance.
CHC providers are notoriously bad at coding. Don't believe me. Look at the data. CMS limited payment of multiple encounter rate payments at CHCs on a single date of service because... wait for it... less than .5%1 (that's right, half of one percent) of all claims submitted to CMS indicated a CHC patient sees more than one core provider on a single date of service. So all that talk about "integrated health" modeling (for which CHCs should receive kudos and credit) seems incredibly unsubstantiated. In other words, CHC patients may regularly see a combination of primary care, behavioral health, and other social service professionals on a single date of service but no one can demonstrate it happens.
Hear's a more recent, albeit anecdotal, example. We visited in early May, a CHC in Massachusetts; i.e., a state which is chest deep in Romney Care... which was the precursor to the Affordable Care Act (a.k.a ACA and Obama Care). All doctors, NPs, PAs, etc. (think CHC core providers) in the state receive a risk score based on the "complexity" of patients seen. The larger group practices (think entire CHC) receive an aggregate or corporate average based on how their employed providers perform. How is this "risk score" calculated? You guessed it. Coding.
Let’s face it. There are very few things that your CHC can do to immediately and profoundly increase income. Sadly you can’t magically increase your encounter rate, get your largest commercial payer to pay 20% more or suddenly compel your patients to pay more (or anything for that matter). What you can do however is increase the average number of visits per hour seen by your core providers (i.e., doctors, NPs, PAs, CNMs, CDEs, etc.). So the question… how many visits per hour do you see currently and how many should you be seeing?
Well, maybe the first question is how you determine the available hours. Let’s say your CHC affords your core providers 4 weeks of Paid Time Off (i.e., PTO which can be sick, vacation, hooky, whatever). And, let’s assume (dangerous, I know) you also afford 20% of a forty-hour work week for administrative time… so 32 hours to see patients.
Let’s agree the above assumptions are sensible or at least a good starting point. There are several theoretical ways to calculate visits based on CHC core providers who follow 48 work-weeks/year and 32 work-hours/week:
So, what do you do with all of this? First, calculate your numbers and share them with your providers. Initially, it will mean very little to them… maybe even to you. My Dad has told me since I was a kid… compare yourself to others and only two outcomes exist: vanity or jealousy. Your providers will either be proud of being the leader, embarrassed about being the laggard, or find excuses for being in any rank-order position. Let’s move past judgment and blame and go to the next level…OPTIMIZATION. Here are some options to elevate production:
Listen, we are not naïve enough to think this is easy but you must change the current paradigm or you just remain stuck where you are. How much additional clinical income would replace, entirely, your 330-grant income? What would your CHC look like in a totally fee-for-service (FFS) world vs. encounter rate AND how many visits per hour would keep you fiscally solvent? What is your average payment visit compared to average expense per visit and how do we close the gap or expand the positive delta?
There are other questions or motivations but make no mistake, with some attention and team focus your CHC can decrease wait time, elevate efficiency, and capitalize on an expanding base of ACA-Medicaid and aging (expanding) Medicare patient base.
Act now. Be a leader. And watch your CHC prosper for years to come.
Charge Setting at your CHC…
Maximize Opportunities with Prudent Planning
New HRSA SFDS PIN, Medicare Rate Hike,
& Medicare “G” Codes Create Perfect Storm
Too often when we ask a CHC CEO or CFO about their fee schedules or the sliding scale, we are met glazed eyes and/or defensive posturing. Many CFOs claim they inherited the schedule, CEOs don’t necessarily understand it, and board treasurers… well, most don’t know where to begin. Just keeping up with legislative updates can be tedious.
Sliding Fee Absolutes.
In September, HRSA released a long awaited Policy Information Notice (PIN) surrounding development of a Sliding Fee Discount Scale (SFDS). After years of HRSA staff telling CHCs what was or was not permissible based on his/her subjective thoughts on the subject… we finally have concrete guidance. This 16-page document reiterated some historic imperatives. Here a few biggies:
In the end, a CHC uses the SFDS to meet mission expectations; i.e., bring down barriers to care felt by your community members. You exist to assure access to affordable health care, for all who seek it. However, optimizing the sliding scale.. and over all charge schedule… is paramount to affording your patients ongoing access to a fiscally viable institution. As we say at PMG, “You need to get paid when you can so you can afford to give it away when you want.” Sliding fee scale development is just part of the overall charge setting process that requires annual attention.
Healthcare providers (e.g., doctors, hospitals, CHCs, etc.) should always charge more than they expect to get paid. If ever you are paid what you charge, your charge is too low. Yet, we still visit scores of CHCs who are paid what they charge. For instance, they set a charge for CPT code 99213 at $50 and are paid $50 by Blue Cross, Aetna, United, etc. This means they would likely have paid you more. You always want a contractual adjustment, a write-off, which assures your charge exceeds the total amount a payer is/was willing to pay. We know you know a CHC exception exists around encounter rate compensation when/if paid “direct” from Medicaid and Medicare… but wait even Medicare is now changing their position on this.
Raising rates is a bad thing?
Surprising to PMG, the elevation of the Medicare encounter rate ceiling from $108 and $128 (rural and urban, respectively) to $158.85… was met with consternation and negativity. How could THE federal payer raising rates… the payer from which most other payers get their payment policy… and a payer representing a rapidly expanding market for CHCs… make CHC leadership angsty? Well, CHCs are now obligated to assure their charge schedule is set to maximize this elevated rate.
Historically or the time being, CHCs submitting claims directly to Medicare are remitted payment at 80% of the encounter rate. Your current Medicare cost report rules until you file one post Oct 1, 2014. CHCs will transition to the new rate with late arrivals finally gaining access to the new rate by early 2016. According to historic conversation and reading of NACHC research, the vast majority of CHCs (if memory serves better than 80%) are at the rural and urban encounter rate ceiling. Stated otherwise, the cost of each Medicare visit is above the $10/$128 ceiling. Again, elevating rates to almost $159 is good news right?
Well, Medicare payment policy for CHCs has afforded the CHC payment of the encounter rate regardless of the charge. If a CHC only coded, say, for a 99212 at $40… they would receive the full encounter rate of $108/$129 dependent on the rate approved by Medicare after acceptance of a CHC’s Medicare cost report. Sure you had to perform some negative net adjustments but geez, who would complain if you got paid 2-3 times what you charged? Not most CHCs. They gladly took the money and ran.
With the new Medicare rate and updated policy, CHCs will now receive 80% of the new rate or 80% of the charge… whichever is less. So, suddenly setting charges and correct coding become seemingly more significant. Truth is, and don’t believe me, ask your providers… if your core providers accurately use the full compliment of HCPCS (e.g., CPT) and ICD codes at their disposal to capture the breadth and scope of services rendered to Medicare patients seen AND you set charges commensurate with local prevailing rates… it will be a rare exception that charges will fall below the new rate. However, people fear what they don’t know or understand.
And now G Codes!!
I will admit this next part… the new G codes… is particularly vexing. This is due largely because it is truly unprecedented with no formal/approved guidance on how to determine pricing for the G codes. Secondarily, it requires a level of coding and billing expertise that is all too rare at most CHCs. Let me back up and show you the G codes:
So, several questions your CHC has to answer:
We meet a surprising number of CHCs who choose to not seek any reimbursement from Medicare because to them it is too complicated. To us at PMG, that is nuts. Don’t get me wrong, the G codes and the new encounter rate upped the ante in terms of your revenue cycle team needing an expanded knowledge base. These new statutes are neither easy to understand nor implement. We don’t expect a CEO or CFO to know the answers but you better have a pretty savvy bunch to work you through this. And, if in-house expertise is less than stellar, don’t be too proud to ask for assistance from an outside firm. The last thing your CHC needs is OIG investigation of abusive coding practices or false claims filing… all stemming from incompetence (or ignorance) and confusion.
What to do?
So, some quick suggestions:
I regularly raise a glass to toast to the complexities of health care. It's how I’ve made a living the past 20+years. It is a crazy, ever-changing environment and (oddly) I love it. The aforementioned changes, if embraced and faced head-on, will put your CHC in a markedly improved position. Getting charges “right,” creating a SFDS that is uniformly and equitably applied to benefit all patients, and holding your providers accountable around optimal coding… these make your CHC more fiscally sound… an elevated performer.
I like to play golf and as I hit an errant shot (thankfully with less regularity), I remind myself of that old saying, “If golf were easy, nobody would play.” If CHC revenue cycle were easy, we would all have different careers because perhaps we would not be needed. The fact is, healthcare coding, billing, and reimbursement is complex, morphing, and a domain where only the hearty survive. It ain’t easy, so play hard. And win.
I write as I am crusing, according to our pilot, at 37,000 feet heading to Phoenix for work at the Region IX conference. Most of my family is flying on another flight back to RI after a brief but wonderful vacation in Florida. Picture perfect weather, wonderful memories, great food, and all too precious (and never enough) time spent with my wife and two of our four kids. Truly this sort of time is, for me, really why I work hard...what inspires me. What inspires you?
Chances are it's not the Affordable Care Act, ICD-10 delay, dwindling grant funding, meaningful use deadlines, and the host of other challenges impacting the US healthcare system and CHCs in particular. In fact, most people don't know about it and as a result, could care less. For CHCs and all those working to make CHCs more profitable, stable, and sustainable...these challenges matter and, in some odd way, inspire us.
Here are some quick thoughts about how you can capitalize (and maybe be inspired) to conquer the aforementioned challenges:
As always, these are just a few items that might keep you up at night. As they say, control the things you can control. These few items are tangible and very controllable. Make someone on your team accountable for each. Set goals, measure progress, and ready your CHC for the never-ending constant in the world of healthcare...Resistance is futile. Be inspired to help lead your CHC to be the best it can be.
Participate, share ideas and discuss issues with other professionals and PMG experts