Raymond Jorgensen

Raymond Jorgensen

CEOTo 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.

NPI 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.

Enrollment
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.

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:

  • Necessary credentials/degree (e.g., MD, DO, PA, NP)
  • Residency or training
  • Board certification or advance training
  • Drug Enforcement Agency (DEA) number
  • State/federal licensure 

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.

Summary
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 employed providers or facilities are not adequately credentialed
  • CHC providers can't or won't be credentialed due to work, licensure, or malpractice anomalies
  • CHCs struggle to manage internal resources/information to maintain active "par" status through re-enrollment

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.

SOSCongressional 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:

  • CHCs provide primary health care for 34%of the > 71 million Medicaid enrollees. If ACA fails, percent goes up.
    • CHCs offer "cradle to grave" care for newborns to elderly; e.g., primary care, Ob-Gyn, dental, behavioral health, 340b (discounted) pharmacy, and more.
  • Preventive care and screenings are a permanent fixture of CHC service offerings.
  • Federal PPS methodology affords CHCs the ability to see all patients regardless of ability to pay.
  • Sliding Fee Discount Scales (SFDS) are mandatory. CHCs slide fees based on Federal Poverty Guidelines.
    • Patients pay what they can afford based on an already existing federal schedule.

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
4 https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html

Locum tenumsToo 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.

Locum Tenens

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:

  • "[Part B or the Medicare Administrative Contractor (MAC)] may pay the patient's regular physician for services of a locum tenens [a.k.a. substitute] physician during the absence of the regular physician where the regular physician [or CHC] pays the locum tenens on a per diem or similar fee-for-time basis..."
  • "The substitute physician generally has no practice of his/her own and moves from area to area as needed."
  • "The substitute physician does not provide the visit services to Medicare patients over a continuous period of longer than 60 days..."
  • "The regular physician identifies the services as substitute physician services meeting the requirements of this section by entering HCPCS code modifier Q6."

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:

  1. 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.

  2. 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.

  3. 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:

  • 30.5.C, while a non-CHC service, the last paragraph anecdotally explains the “billing provider” must be physically present in the clinic setting where the “incident to” service is being rendered.
    • I.e., a CHC may not just use the Medical Director’s NPI as s/he is never always present in a singular clinic setting.
  • 30.6.B clearly states “incident to” only works for Part B payments
    • Remember, as with locum tenens, Medicare PPS is paid to CHCs via Part A payment methodology. This alone negates “incident to” options for the vast majority Medicare payments. The only exclusions or carve outs are the Part B services.
  • 30.6.4 covers Evaluation & Management (E&M) services rendered “incident to” by NPs, PAs, CNMs but billable under a physicians NPI.
    • While desirable in the Part B world to avoid the payment reduction for “non-physicians” this does not happen at CHCs as ALL core providers are paid the same PPS rate.
    • In other words, whether service is rendered by a NP, PA, CNM, or doctor, the CHC’s PPS rate is identical.

While these statutes are enlightening, please remember:

  • They only apply to Medicare, not Medicaid.
  • (And, this is herein intentionally repetitive) CHC core providers are paid by Medicare via PPS rate, not Part B; the latter is via the Physican Fee Schedule (PFS). The only exceptions are diagnostic tests and CHC services not eligible for Medicare PPS payment.
  • Again, CHCs are paid by Medicare via group NPI; i.e., NPs, PAs, CNMs, and doctors working at CHCs are ALL paid the same PPS rate via the PPS “G” codes.

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:

  • 10.2 lists “incident to” services as covered
  • 120 reviews typical services rendered “incident to” a billable provider but most important… Medicare payment must meet PPS G code requirements
    • I.e., CHCs may receive PPS payment only when face-to-face encounter occurs between a Medicare beneficiary and a CHC core provider.
    • AND, even then, only if the core provider renders a service that falls under the CPT code range defined under the PPS G codes.
  • 120.1 includes several key elements…
    • Rendering staff must be 1099 or W-2 employee; i.e., no volunteer providers allowed… that is if the CHC wants to be paid.
    • Multiple “incident to” visits may result from single core provider visit.
    • “Direct Supervision” is defined as the “billing provider MUST be “immediately available” in the CHC clinic area.
      • Medicare has used the phrase “within shouting distance.”

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:

  • The only nationally accepted, federal statute substantiated policies cover fee-for-service (FFS) Medicare.
  • CHCs receive very little FFS Medicare money due to the all-inclusive PPS payment.
  • Medicaid and Managed Care plans may have policies but they are not standard. Your CHC must find written substantiation in statute for Medicaid and contract language for managed care plans. If none exists, the policies don’t exist for those payers.
  • Yes, the Medicare FQHC manual states “incident to” services are covered at a CHC but Medicare PPS payment still only happens when there is a medically necessary face-to-face encounter between a core provider and a Medicare beneficiary.
  • There is in a CHC no legitimate reason to use “incident to” billing. If a core provider has their own NPI, bill payers using it. If not (and no contract or statute language affords other options), s/he is not billable to any payers requiring the 837-P.

Summary

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:

  1. “Why?” and

  2. “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.

1 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c01.pdf

2 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf 

3 https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c13.pdf 

 

Monday, 19 September 2016 16:10

Top 5 Reasons PPS G Codes Need Code Expansion

Medicare G CodesCoding 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:

  • G0466: General medical, new patient
  • G0467: General medical, established patient
  • G0468: Initial Periodic Preventive Exam (IPPE) or Annual Wellness Visit (AWV)
  • G0469: Mental health, new patient
  • G0470: Mental health, established, patient

As a taxpayer and businessman, the transition was to me sensible for two primary reasons:

  1. 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."

  2. 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:

  • Not all core provider services require E&M visits. Admittedly, much CHC clinical work falls under an E&M service. However, national correct coding policy stipulates that a patient presenting for a procedure only visit (e.g., toe nail repair, wart destruction, incision and drainage, etc.) should be coded and billed with only a surgical code. An E&M might also be appropriate but only if a "-25 modifier opportunity" presented (i.e., a significantly and separately identifiable issue was addressed at the time of the procedure). Further, other covered Medicare services like chiropractic or osteopathic manipulative treatment are correctly coded with just a "subluxation" or "manipulation" code, again without an E&M service. Under the present coding system, these services are rendered by CHCs without CHCs receiving payment. In fact, the majority of the excluded codes are from largest section of CPT; i.e., the surgical section representing CPT codes 10000-69999.
  • Compelling less seasoned coding/billing focus to code/bill incorrectly. Most CHCs are admittedly substandard around coding. Their historial "encounter rate" payment made it seem pretty insignificant. However, CHCs well understand the encounter rate or "qualifying visit" payment "trigger" which has been a face-to-face encounter between a patient and a core provider. This consultant fears too many are now adding an E&M service just to trigger this payment.
  • Inabilty to capture full breadth and scope of services. The over capture of E&M because of item 2. herein, is not only inappropriate coding but it undermines the integrity of data capture intended to understand what services CHCs are actually providing. Change Request 7038 (January 2011) was created so CMS could evaluate all the services CHCs are offering. This present PPS G code limitation around HCPCS is antithetical and sends an incredibly mixed message to CHCs.
  • Handicapping CHCs ability to prepare for MIPS. HCPCS (again, think CPT) are used for risk-determination/underwriting by third party payers when working in the professional vs. facility realm. In other words, professional vs. facility providers (e.g., CHCs) paid under the Part B, CMS 1500, and ANSI 837-P models have "risk" evaluated based on the HCPCS codes captured. This is incredibly significant as CHCs prepare for Alternate Payment Methodologies (APM) under MACRA/MIPS and other state managed Medicaid models. While we understand MIPS will mostly focus on fee for service (FFS) dollars paid under the professional fee schedule (PFS), CHCs expect PPS (both Medicaid and Medicare eventually) to eventually be impacted. How can CHCs get a fair shake in terms of capture of all services if the code list they are allowed to submit is so truncated?
  • Discrimination against Medicare beneficiaries. In an effort by CMS to assist CHCs with questions or issues around the PPS G codes, a FAQ document was published2. Aside from the "new patient" definition contradicting CPT text (and all other payers in the healthcare world) and too many MAC staff not even understanding what a CHC is/does, page 8, question 9 seems to clearly set precedent for CHCs to discriminate against Medicare patients seen at their offices by compelling the patient to sign an Advanced Beneficiary Notice (ABN) and pay cash for a service covered by CMS in any other outpatient (Part B) setting. Here are two very real scenarios:

    • Medicare beneficiary with Type 2 Diabetes arrives for medical necessary toenail debridement. No other issues exist. The core provider performs the service and codes 11720-11721 depending on how many nails are debrided.

    • Medicare beneficiary with an inflamed boil arrives today after being seen yesterday. S/he has taken oral antibiotics and arrives today to have the boil incised and drained. CPT code 10060 is the standalone code as no other services are rendered.

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.

1 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/RHC-Qualifying-Visit-List.pdf

2 https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/FQHC-PPS-Specific-Payment-Codes.pdf

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/FQHCPPS/Downloads/FQHC-PPS-FAQs.pdf 

 

 

Credentialing ViolationMany 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.

  • Credentialing vs. Enrollment. Enrollment is the process of getting providers or facilities (e.g., CHC clinics) into participation status with payers. Being a participating provider/clinic is essential to see a payer's or plan's members and be paid an optimal fee schedule. Credentialing is the actual assignment of participating provider status after the provider/clinic credentials have been thoroughly vetted by each payer. Enrollment is the process of submitting application to credentialing committees at payers. So, enrollment processes results in credentialing of providers with payers.
  • Individual vs. Facility (Clinic) NPIs. Nearly all payers require a unique NPI for all CHC core providers. Remember this means not just doctors but most mid-levels or non-physicians (e.g., physician assistant). At CHCs, Medicare Part A (think PPS and G codes) are billed via the ANSI 837-I (institutional) vs. Part B (think fee-for-service for diagnostics and non clinic encounter work) via the 837-P (professional). The 837-I is a group number and as such ANY employed providers (even those starting today) may have PPS visits billed under the group NPI. However, Part B... and nearly all other payers... require the 837-P necessitating the individual provider to be credentialed with each payer. This means until the provider is fully credentialed your CHC is unable to even submit claims to those payers requiring 837-P claim format.
  • Billing New Providers Under Other Staff NPIs. Hiring new core providers is expensive and getting paid as quickly as possible for work they provide to patients is obviously quite desirable. PMG finds too many CHCs billing work rendered by the new core provider under the medical director or other already credentialed staff. Unless your CHC has a statement in writing from a respective payer which allows billing under another provider's NPI, this is patently illegal. It is fraud with a capital "F." The preceding example of Part A Medicare is an exception but don't fall into the trap of "everyone does it" or "we have to get paid" because you will lose this battle. One Qui Tam phone call or claim inquiry from a payer could result in fines/penalties well exceeding any lost dollars from not getting paid for the first months the new provider is employed. A good strategy is to have new providers see cash patients, grant funded patients, and Medicare Part A... no individual credentialing necessary for these payers. This is not always possible but will mitigate loss and risk.
  • Medicare Exclusion List. Most CHC leadership remain blissfully unaware of pitfalls resulting from not regularly (think at least quarterly but preferably monthly) reviewing the Medicare Exclusion List for ALL staff but especially for providers. There are companies that can manage this for a CHC but a quick check of the OIG site is pretty easy (https://oig.hhs.gov/exclusions/). Remember, it is against the law to bill a government payer while employing an excluded person. A person could be on the exclusion list because they worked at a facility that had been penalized or a provider for something as seemingly innocuous as not repaying a federal student loan. Check the list. Avoid this easily avoidable issue.
  • Non-physician Practitioners (NPPs). NPPs is the term CMS using to define nurse practitioners, midwives, physician assistants, certified diabetic educators, and the host of other clinical staff who are able to be assigned NPI AND be credentialed by CMS for individual payment. Most third party payers (but not all) mirror CMS policy around credentialing. Certain payers (e.g., Aetna) has historically not credentialed NPPs. However, most other payers do. Not credentialing NPPs when a payer requires it creates liability for your CHC. Some CHCs have told PMG they don't credential NPPs because they get paid more money for submitting their work under a doctor. The "F" word was mentioned earlier and this overtly deceptive practice of seeking more money than warranted is at worst an abusive billing practice and at worst, a fraudulent act. Bottom line: if a payer credentials a NPP, get them credentialed and use their NPI for submission to all possible payers.

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.

shutterstock 244444573CHC 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:

  1. Medicare Cost Report… 4,200 visits/doc.  We know Medicare has moved to the elevated PPS making the “4,200” visits per FTE perhaps a tad passé. However, let’s simply divide 4,200 by 48 weeks (resulting quotient is 87.5) and divide this quotient by 32 hours. The final, important quotient is 2.73 visits per hour. Again, this is just the average, some core providers see more, some less.
  2. UDS Averages.  According to national UDS data (2013, i.e., http://bphc.hrsa.gov/uds/datacenter.aspx?q=tall&year=2013&state), the national CHC average of visits per hour (using 48 work-weeks per year and 32 work-hours per week) is 2.0… for medical providers. Dentists are at 1.7/hour and behavioral health providers, .78/hour. Again, these are averages and we know UDS data is questionable in terms of data integrity BUT you need to at least consider this data (we think) in order to make informed business decisions.
  3. National Family Practice Average.  Forgetting dental and behavioral health, the average for Family Practice is, to me interestingly, 2.74 or just barely above the number Medicare historically expected CHC providers to see. Read the full article at http://www.washingtonpost.com/news/to-your-health/wp/2014/05/22/how-many-patients-should-your-doctor-see-each-day/). These are national averages for Family Practice and so a comingled data set of for profit, not-for-profit, academic, and other employed providers. Interestingly, the average number of weekly hours in face-to-face contact with patients is 34… slightly above the 32 we used.
  4. Hire certified coders to alleviate the coding burden for providers. If they see (literally) one more visit per day (i.e., 5/week or 2,040/ year) at a UDS average of $114/visit, you make an additional $232,000. Don't know how much certified coders make in your market but it’s not greater than $200,000.
  5. Optimize your EMR by finding your most productive provider and making them your star. What do they need to see even more patients? More support staff, a scribe, more optimal clinic setting? We say get them what they need! Keep in mind that one extra patient per day means more than $200,000 with which we can play.
  6. Implement incentive based compensation. For some of your providers, having the opportunity for them to personally make more money… that is enough. For others, think of it like “restricted” or “targeted” fund raising. They need to produce X to get Y. Want a Certified Diabetic Educator? Expanded mobile outreach? Homeless health services? Whatever. Show them how much money you need and how increasing visits per hour can make it happen.

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:

  1. Cover reasonable costs and make your fee/charge schedule commensurate with local prevailing rates.
  2. Assure uniform and consistent application of SFDS policies and FPL determinations.
  3. Disallow SFDS eligibility if no paperwork provided. If patients don’t present necessary paperwork as defined in your SFDS policy and procedure, your CHC does NOT have to discount charges.
  4. Allow a CHC to have policy around charging a “nominal fee” to patients  at or below100% of FPL… even for SFDS eligible patients.
  5. Allow a CHC policy to release (i.e., stop seeing) patients who do not comply with payment of these predetermined nominal fees… emergencies obviously excluded.
  6. Utilize a “flat rate” sliding scale vs. discounts for each HCPCS (e.g., CPT) code… the latter making your team dependent on accurate and timely provider coding which is often wanting.
  7. Require annual approval/review by the board so they can assure your CHC’s SFDS is not creating a barrier to care.
  8. Afford non-SFDS discounts for patients above 200% of FPL… as long the determination or funding source is separate/distinct from your CHC’s published SFDS and the discount can be applied without preferential treatment.

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:

  • G0466 – FQHC visit, new patient
  • G0467 – FQHC visit, established patient
  • G0468 – FQHC visit, IPPE or AWV
  • G0469– FQHC visit, mental health, new patient
  • G0470 – FQHC visit, mental health, established patient

So, several questions your CHC has to answer:

  1. What services are included in each of these codes? They don’t crosswalk directly to any singular CPT codes so you get to decide.
  2. Do you average fees for all new vs. established patients divvying data by medical vs. mental (behavioral) health?
  3. All services must be submitted on the same claim. What if you submit claims to more than one Medicare Administrative Contractor?
  4. Who assigns the G code? Your EMR/EHR has required your providers to perform “charge entry” (i.e., selecting CPT and ICD) which starts billing but you don’t want them coding Medicare patients differently from other payers, right?

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:

  1. Design a process for annual review and setting of charges including SFDS. HRSA says you have to and it is just good business with fiduciary accountability at the core.
  2. Move to a flat rate sliding fee. It is easier to explain internally and for patients while simultaneously removing dependence on provider coding.
  3. Monitor coding patterns by your providers. You must hold them accountable around documentation and corresponding coding to assure what they document/code demonstrates the acuity/complexity of rendered services. This will help with Medicare changes AND elevate your game as risk adjusted compensation moves in.
  4. Create a methodology for determining pricing for G codes. This is not going away so whether you simply add up all Medicare charges and divide it by total visits (and decide whether to include “carve out” services that go to Part B via ANSI 837P)… create a process and follow it.
  5. Assign a C level person to be accountable. Normally this is the CFO but we have met many CEOs who feel this is so important; they want to be in the know. Don’t be caught off guard. Create a chain of command, a timeline for creation, and subsequent checks and balances. Follow it through with diligence.

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:

  • ACA:  One stop patient registration, preferably electronically, with your team directing your uninsured patients to the payer your CHC likes best.  Which pays best and fastest?  Which benefits are more robust and/or easier to explain to patients?  Which plan has the best customer service...Hint: ask your patients what they think.  Master front desk efficiency and accuracy and know which plans are ideal for your CHC.  Your patients will ask you...be ready with the answer AND the registration process.  It will positively impact your bottom line.
  • ICD-10 Delay: I won't belabor this further except to say...you have more time to do a more thorough job getting your ICD house in order.  Yes, we all ponder if ICD-10 will ever happen.  It will take an Act of Congress to revert back to ICD-9 so don't plan on it going away.  AND...as we've discussed before, improving your CHCs ICD coding now will benefit your CHC because:
    • ICD-10 coding process is nearly identical to ICD-9 but with more codes.  Learn optimal ICD-9 for smoother transition to ICD-10.
    • Pay for Performance and/or Risk Adjusted Compensation is on its way. Sure you will still have to submit fee-for-service (FFS) claims but ICD will dramatically impact future reimbursement...You can count on it.  
    • ICD-9 is simply inadequate in terms of affording your CHC the opportunity to better demonstrate the breadth, complexity, and scope of medical (not to mention socio-economic) challenges managed by your team.  Only ICD coding can prove this.  Get better at this or continue to look, according to data, less challenged than most private practices.
  • Dwindling Grant Funds:  Can you imagine your CHC being financially independent from grant funding?  What is the delta between your Cost/Encounter (CPE) and Payment/Encounter (PPE)?  If you don't know these data, you should.  If your CHC team does not know these data, how can they work to make your CHC at worst a break-even business or, ideally, surplus (dare I say profit) drive?  Find the data, share it with your team, and be inspired by the progress that can/will be made.
  • Meaningful Use (MU):  So tell me you at least have your MU1 achieved so that only MU2 remains as your most significant hurdle.  I am not a MU expert BUT the diminishing compensation from Medicare FFS (Part B) is reality and don't be surprised if other payers are soon to follow.  It is highly probable that you have been live on your EHR for a while.  Have you optimized your workflow among all specialties and focused on increased, quality patient engagement? Optimizing a truly functional EMR/EHR with quality patient engagement needs to become the norm.  ASAP.

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.

 

By now you have most likely heard about the probable delay of ICD-10, again.  H.R. 4302-Protecting Access to Medicare was passed by the House of Representatives and in all probability should breeze through the Senate before being signed into law by President Obama.  Aside from the standard (i.e., essentially annual) "Medicare Pay Fix," this bill, once law will delay ICD-10's start date until October 1, 2015.  This puts everyone in basically one of two camps… those who got ICD-10 ready (i.e., Team Ready) and those who did not (i.e., Team Tardy). Following are thoughts for those in both camps.

Team Ready

(NOTE: PMG’s revenue cycle management (RCM, a.k.a., billing)

AND PMG-Consulting’s ICD-10 clients… this is you!!)

  • Like someone preparing for a road race or athletic event that gets postponed… do you really want to let all that hard work go to waste? You prepared, trained, and made the effort to get in shape. Don't become a couch potato after all the work you’ve done to get here now.
  • Start using ICD-10 as planned no later than October 1, 2014 allowing your billing team to crosswalk the ICD-10 code back to the ICD-9 code. 
  • By actual implementation timeline in 2015 or beyond, your team is seasoned and ready to accept ICD-10 transition like it was nothing.

Team Tardy

  • No matter what we say or recommend, procrastination may be your standard modus operandi.
  • We will tell you (again) to start (now) to:
    • Evaluate your current ICD documentation through chart audit,
    • Make certain you are on the most current version/release offered by your EMR/EHR and practice management vendor,
      • Only this release can concurrently manage ICD-9 and ICD-10 data files.
    • Train your providers on optimal documentation,
    • Search historic coding patterns for troubling trends, and
    • Find gaps in system operations where the shift from ICD-9 to ICD-10 will cause issues.

But these are not new suggestions. We at PMG are, frankly, disappointed to see the delay come forth. Mostly because most of those complaining loudest about not being ready will do what they did last time a postponement was afforded… absolutely nothing.  If you are a member of Team Ready, you will always be prepared. If you associate more with Team Tardy… Now is your chance to join the winning team!  

National provider entities and their lobbyists have stated that the majority of providers are simply not ready to move.  This transition is, however, not optional.  As the only industrialized nation in the world not using ICD-10, the U.S. is the weak link in the work of public health data.  It is a public health imperative to move to ICD-10.  AND, Congress passed a bill into law requiring ICD-10 as part of the national standardized code set.  

Perhaps more importantly, our CHC clients have proven time and again that the optimal motivator when attempting to bring about change in process or behavior is doing the right thing for the betterment of:

  • Patient care and outcomes,
  • The local and national healthcare community, and
  • The larger world of public health.

These are things our clients and their providers can get behind.  Moving purposefully to ICD-10 affords our national healthcare community the opportunity to:

  • Expand and more accurately capture the complex breadth of challenges seen in community-based medicine
    • Current ICD-9 data suggests CHC patients are the same or less complicated than those seen in private practice, which we know from first-hand experience to be false. 
  • The ability to share more meaningful data with the National Center for Vital Health Statistics (NCVHS) and the World Health Organization (WHO)
    • NCVHS exports mortality data to WHO annually but as a nation we cannot communicate internally at more than a cursory level regarding the complexities of disease being managed.
  • Enhance historically inadequate “assessment and plan” documentation to mitigate audit risk and/or jeopardized patient care.
    • If you have not done an ICD-9 audit recently, take a look and see if your providers’ documentation will pass ICD-9 scrutiny, never mind ICD-10.

We make no bones about the fact that we at PMG are hired to make our clients money.  Certainly, from a revenue perspective, maximization of risk-adjusted compensation is always a topic of interest. ICD-10 brings this opportunity forward. We must grasp it.

So, for now, if you are Team Ready… stay the course. You worked hard to get here so don’t backslide. Start using ICD-10 no later than October 1, 2014 and allow your practice management system to crosswalk back to ICD-9.

If you are Team Tardy… you may have already stopped reading… but make a bold break from a history of procrastination and start ICD-10 preparedness NOW. Initiate a move to ICD-10 for the betterment of your patients and public health.

By the entirety of the United States’ healthcare community enhancing their documentation and coding, we all collectively benefit from data on which we can depend and make the best decisions possible. We at PMG are committed to making certain our clients are best of breed in this regard. Thanks for allowing us to be your partners as we move boldly forward through the ever-changing complexities of our national healthcare system.

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