RHC Manager 101

Teresa TreiberManager – Rural Health Team

Spectrum Health

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RHC Manager 101

Objectives:

o Learn some basics that all practice managers need to know to

run a successful RHC

o High-level overview of major differences when managing an RHC

o Discuss tools to help maintain RHC compliance

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RHC Manager 101

What is an RHC?

Rural Health Clinics (RHCs) were established by the Rural Health Clinic Service Act of 1977 to address an inadequate supply of physicians serving Medicare beneficiaries in underserved rural areas, and to increase the utilization of nurse practitioners (NP) and physician assistants (PA) in these areas. RHCs have been eligible to participate in the Medicare program since March 1, 1978, and are paid an all-inclusive rate (AIR) for medically-necessary primary health services, and qualified preventive health services, furnished by an RHC practitioner.

(Medicare Benefit Policy Manual. Chapter 13. Section 10.1.)

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RHC Manager 101

Staffing

42 CFR 491.8(a)(6) states that a RHC shall have a physician, nurse practitioner, physician assistant, nurse-midwife, clinical social worker, or clinical psychologist available to furnish patient care services at all times the RHC operates.

It further states that at least 50 percent of the time the RHC operates a nurse practitioner, physician assistant, or certified nurse-midwife is available to furnish patient care services.

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RHC Manager 101

Direct Services – 51% Primary Care

An RHC is required to be primarily engaged in providing outpatient or ambulatory health care services. In accordance with §§ 405.2411 - 2416, RHC services include the services of physicians, NPs, PAs, certified nurse midwives, clinical psychologists and clinical social workers, along with the services and supplies that are incident to these practitioners’ services.

RHCs are not prohibited from furnishing other services, however, they may

not be primarily engaged in providing such specialized services. In the context of an RHC, “primarily engaged” is determined by considering the total hours of an RHC’s operation, and whether a majority, i.e., more than 50 percent, of those hours involve provision of RHC services.

Interpretative Guidelines § 491.9(a)(2) & (c)(1)

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RHC Manager 101

42 CFR 491.8(a)(6) states that a RHC shall have a physician, nurse practitioner, physician assistant, nurse-midwife, clinical social worker, or clinical psychologist available to furnish patient care services at all times the RHC operates.

RHCs may allow beneficiary entry to the waiting room or other non-patient care areas to handle

billing inquiries or to get out of the weather when the mid-level practitioner as defined in §493.2, clinical social worker, clinical psychologist or physician member of the staff is not present under the following circumstances:

An RHC that opens its premises solely to address administrative matters (including allowing patients entry into the building to get out of inclement weather) is not considered to be in operation as an RHC during this period.

CMS emphasizes that no health care services shall be provided until a mid-level practitioner as defined in §493.2, clinical social worker, clinical psychologist or physician staff member is present to provide services.

CMS issues letter to State Surveyors Ref: S&C-07-06

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RHC Manager 101

Process to become a Rural Health Clinic – High level overview

Process can take 8-12 months depending on multiple factors.

1. Initial Application

- Multiple Federal and State forms

2. Site Survey

- Completed by state or by deeming agency

3. Finalization of application

- Assignment of PTAN

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RHC Manager 101

Types of RHC’s

Independent RHC - are stand-alone or freestanding clinics.

Provider-based RHC – is an integral and subordinate part of a hospital. It is very important to understand that provider-based RHC’s are NOThospital departments. They are considered a provider-based entity of the hospital. The RHC bills under the hospital tax ID but is assigned it’s own unique PTAN/CCN number.

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RHC Manager 101

Cost Report

o Must be filed annually

o Determines the cost-per-visit and the all-inclusive payment rates.

o Reconciles Medicare’s interim payment method to actual cost per visit.

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RHC Manager 101

Billing and Reimbursement

An RHC encounter is a medically-necessary visit with an eligible RHC provider (MD,DO,NP,PA,CNM,LCSW,Pyschologists)

RHC’ are paid at an all-inclusive-rate for each billable visit. Rates are established via the cost report based on the formula

Allowable costs /total visits=Rate

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RHC Manager 101

Billing and Reimbursement

Independent RHC’s and Provider-based RHC’s owned by a hospital with over 50 beds have a capped rate-per-visit of $83.45

Provider-based RHC’s owned by a hospital with less than 50 beds have an uncapped rate-per-visit.

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RHC Manager 101

Billing and Reimbursement

Medicare RHC visits are billed on a UB-04 claim form

Medicaid RHC visits billing form depends on each state’s rules.

All other commercial claims are billed on a 1500 claim form.

Claims are billed to the Part A MAC and paid under the patients Part B benefit.

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RHC Manager 101

Billing and Reimbursement

POC lab and technical charges are billed differently depending on the type of RHC.

Independent – billed separately on a 1500 claim form and reimbursed FFS.

Provider-based – billed by parent hospital as an outpatient service.

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RHC Manager 101

Compliance

New RHC applicants are expected to have all RHC requirements implemented at the time the surveyor presents at the clinic.

Established RHC clinics are expected to follow and maintain RHC regulations at all times.

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RHC Manager 101

Certification/Recertification

Certification is the initial application process to become a RHC.Recertification is the continual review of compliance that the clinic is functioning under federal regulations as a RHC.

Both require an on-site inspection by the state or deeming agency. Both visits are unannounced.

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RHC Manager 101

Certification/Recertification site visit

Condition vs Standard

Standards are the clinic operating processes. You may receive deficiencies in Standards such as expired medications or supplies…etc.

Conditions are severe deficiencies. This type of deficiency can result in having to start the application process over for new clinics and losing your RHC status for existing clinics. Examples include items such as -APP not meeting the 50% requirement, policy review not current or annual advisory meeting/program evaluation is not current.

RHC Manager 101

Laboratory

The RHC provides laboratory services in accordance with part 493 of this chapter, which implements the provisions of section 353 of the Public Health Service Act. The RHC provides basic laboratory services essential to the immediate diagnosis and treatment of the patient, including:

(i) Chemical examinations of urine by stick or tablet method or both (including urine ketones);

(ii) Hemoglobin or hematocrit;(iii) Blood glucose;

(iv) Examination of stool specimens for occult blood;(v) Pregnancy tests; and

(vi) Primary culturing for transmittal to a certified laboratory.

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RHC Manager 101

Emergency Preparedness –

§ 491.12 Emergency preparedness.

The Rural Health Clinic/Federally Qualified Health Center (RHC/FQHC) must comply with all applicable Federal, State, and local emergency preparedness requirements. The RHC/FQHC must establish and maintain an emergency preparedness program that meets the requirements of this section.

Please review the full list of requirements in CFR 491.12

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RHC Manager 101

§491.11 Program evaluation.

(a) The clinic or center carries out, or arranges for, an annual evaluation of its total program.

(b) The evaluation includes review of:

(1) The utilization of clinic or center services, including at least the number of patients served and the volume of services;

(2) A representative sample of both active and closed clinical records; and

(3) The clinic's or center's health care policies.

(c) The purpose of the evaluation is to determine whether:

(1) The utilization of services was appropriate;

(2) The established policies were followed; and

(3) Any changes are needed.

(d) The clinic or center staff considers the findings of the evaluation and takes corrective action if necessary

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RHC Manager 101

§491.9 Patient Care Policies.

(1) The clinic's or center's health care services are furnished in accordance with appropriate written policies which are consistent with applicable State law.

(2) The policies are developed with the advice of a group of professional personnel that includes one or more physicians and one or more physician assistants or nurse practitioners. At least one member is not a member of the clinic or center staff.

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RHC Manager 101

RHC Policy and Procedure Manual

(3) The policies include:

(i) A description of the services the clinic or center furnishes directly and those furnished through agreement or arrangement.

(ii) Guidelines for the medical management of health problems which include the conditions requiring medical consultation and/or patient referral, the maintenance of health care records, and procedures for the periodic review and evaluation of the services furnished by the clinic or center.

(iii) Rules for the storage, handling, and administration of drugs and biologicals.

(4) These policies are reviewed at least annually by the group of professional personnel required under paragraph (b)(2) of this section and reviewed as necessary by the clinic or center.

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RHC Manager 101

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Best Practice

Creating an “Evidence Binder” is recommended.

This binder will house all of your supporting documentation and is your evidence of compliance during a survey.

This will help your survey to be successful and flow smoothly.

Keep the information updated!

Identify key staff who know where this binder is located in the event a surveyor arrives for a survey and the practice manager is not available.

RHC Manager 101

Evidence Binder – recommended list

o Providers State License and DEA

o Health Service Statement – this states the Hours of Operation, and what services the clinic provides, as well as the POC Labs

o Collaboration agreements and prescriptive authority agreements are signed and up to date – annually.

o Yearly electrical inspection report by Bio-Medical Dept

o Fire, evacuation, tornado, EP training logs

o Documented annual training and competency for all staff

o Copy of current organizational chart

o List of current staff, clinical and clerical with job descriptions

o Housekeeping logs

o Current advisory meeting notes/presentation

o Clinical staff BLS certifications

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RHC Manager 101

Additional items that can be housed in the Evidence Binder or a separate binder created for tracking logs

o sample medication Logs

o Medications, biological and sterile supplies checked monthly for expiration dates

o Lab supplies and reagents monthly inventory

o Tracking labs that are referred out

o Patient's rooms checked monthly Log

o Copies of provider-APP chart reviews

A separate hard-copy SDS (safety data sheet) binder should also be available and up to date.

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RHC Manager 101 – RHC Tools

It is recommended that you periodically complete a mock survey assessment to ensure continued compliance.

RHC’s are expected to maintain RHC compliance at ALL TIMES.

**use of the following tools are not required. They are recommended for use to help ensure RHC compliance and identify areas of risk. Links to all of these tools are available to you in your conference material and can be modified to fit your needs.

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RHC Manager 101 – RHC Tools

Mock Survey/Rounding Tools

This mock survey tool is broken down in the following categories:

➢ Environment of Care

➢ Life Safety

➢ Infection Prevention

➢ Sterilization

➢ POC Testing

➢ Emergency Preparedness

➢ Administration

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RHC Manager 101 – RHC Tools

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RHC MONTHLY QUALITY, SAFETY and INFECTION PREVENTION ROUNDING TOOL • IF "NO" IS MARKED FOR ANY ANSWER, THE ACTION TAKEN AND OTHER COMMENTS MUST BE DOCUMENTED

• TCT = The Compliance Team RHC Deeming Agency

Standard

Rationale

Yes No* N/A

Action Taken/Comments and

Initials

Environment of Care

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Is general appearance and are all surfaces clean,

uncluttered, and intact? (This includes furniture, walls,

flooring and high areas; look for tears in furniture, peeling

floors, holes in walls/chipped paint, decals peeling, scuffs

on floors/walls, peeling/chipped laminate)

TCT ADM 11.0; CFR 491.6(b)(3)

3 Housekeeping logs are being maintained. TCT ADM 11.0 CFR491.6(b)(1)

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Is lighting suitable for care, treatment, or services? (This

includes emergency/exit lighting, includes shatterproof

lightbulbs in gooseneck lamps or cover)

TCT REG 1.0

6Is there at least 36 inches of clear space (no obstruction)

in front of all electrical panels? TCT EQP 1.0

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Are tanks of compressed gasses (oxygen, etc.) properly

labeled and secured in holders or chained to the wall?

(labeled "full-ready for patient use" or "empty", storage

clearly separated between full and empty, ambu-bag-

valve-mask ventilation supplies attached to tank, any

used tanks to be considered empty)

TCT EQP 1.0; Adm 10.0 CFR

491.9(c)(3)

8Is staff aware on how to access the SDS Vault in the

event of a chemical spill?TCT REG 2.C

RHC Manager 101 – RHC Tools

Compliance Rounding Tools

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Date of review:

Reviewed by :

Exam Rooms and Procedure Rooms Medication/nurse area

1. room logs being utilized? 31. signage on fridge - do not unplug, meds only..etc.

2. expired meds/supplies? 32. power outage procedure on door of imms

3. plug protectors? 33. anything stored in doors of fridges?

4. closed trash containers? 34. schedule II drugs are double locked and logged separately?

5. holes or spots in walls that need repair? 35. allergy meds monitored separately for expiration?

6. locks on cabinets as necessary? 36. oxygen tanks secured

7. anything under sinks? 37. oxygen tanks labeled in use and empty? Cannula ready?

8. vials ointments and solutions dated appropriately? 38. emergency drug box easily accessible?

9. any single use items opened and not discarded? 39. sample meds logged?

10. cleaning products secured? 40. eye wash station checked and logged?

11. drawers and cabinets neatly organized? 41. spill kit?

12. sharps containers mounted and dated appropriately? 42. any safety concerns?

13. splash guards present? 43. any auto clave process concerns?

waiting room and hallways

Patient Bathrooms 44. holes or spots in walls that need repair?

14. emergency notice in bathroom? System tested? 45. plug protectors?

16. any chemicals or air freshener cans in bathrooms? 46. clean?

17. restroom labeled correctly? 47. Any safety concerns?

18. holes or spots in walls that need repair? 48. lock on cleaning supply closet

19. plug protectors? 49. exit signs can be clearly seen and lights functioning?

50. Secondary doors are locked?

RHC Manager 101 – RHC Tools

Chart Reviews- 2 types

Physician Chart Review

RHC regulations state that a physician must periodically review the records of the RHC. §491.8

The amount of records to review and the frequency is based on your specific state guidelines. If your state does not specify, the surveyor will look to your policy.

You must provide proof of this review that shows both the provider and the APP involvement.

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RHC Manager 101

Surveyor Chart Review

Surveyor will conduct a chart review at time of survey to review the following elements

listed in CFR 491.10

For each patient receiving health care services, the clinic or center maintains a record that includes, as applicable:

(i) Identification and social data, evidence of consent forms, pertinent medical history, assessment of the health status and health care needs of the patient, and a brief summary of the episode, disposition, and instructions to the patient;

(ii) Reports of physical examinations, diagnostic and laboratory test results, and consultative findings;

(iii) All physician's orders, reports of treatments and medications, and other pertinent information necessary to monitor the patient's progress;

(iv) Signatures of the physician or other health care professional.30

RHC Manager 101 –Chart review tool

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Section 1 to be completed by office manager or designated staff for all providers (Physicians and APP's)

Provider Name:_______________________________________ Quarter of review:

MRN Number 1. 2. 3. 4. 5.

Date of Service

For each patient receiving health care services, the clinic maintains a record that includes, as applicable:

Chief complaint or reason for the encounterP A P A P A P A P A

Pertinent medical history and/or surgical historyP A P A P A P A P A

Known long-term medications, including current medications, over-the-counter drugs, and herbal preparationsP A P A P A P A P A

Social data (i.e.. marital status, habits, occupation, etc.)P A P A P A P A P A

Smoking StatusP NA A P NA A P NA A P NA A P NA A

Family hxP A P A P A P A P A

Known adverse and allergic drug reactions;P A P A P A P A P A

Assessment of the health status, including complete vital signs on all patients every visit starting at age 2:

Pain is assessed in all patients. (A comprehensive pain assessment is conducted as appropriate to the patient's condition and the scope of care,

treatment, and services provided.)

P NA A P NA A P NA A P NA A P NA A

HeightP A P A P A P A P A

WeightP A P A P A P A P A

BP (NA under age 3) P NA A P NA A P NA A P NA A P NA A

BMIP A P A P A P A P A

Report of physical examinationP A P A P A P A P A

Clinical impression or diagnosis; Brief summary of each episodeP A P A P A P A P A

Plan for careP A P A P A P A P A

The problem list is initiated for the patient by the third visits and maintained thereafter.P NA A P NA A P NA A P NA A P NA A

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RHC Manager 101 –Chart review tool

Section 2 ( to be filled out by provider for APP charts only)

Physical Exam Adequate

Diagnosis supported by H & P

Appropriate Us of Lab/Xray

Plan/use of meds appropriate

Plan of care appropriate

Provider signature: Date:

APP signature: Date:

Comments:

RHC Manager 101

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RHC Manager 101

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CMS MLN RHC Fact sheet - https://www.cms.gov/Outreach-and-

Education/Medicare-Learning-Network-

MLN/MLNProducts/downloads/RuralHlthClinfctsht.pdf

National Association of Rural Health Clinics –

https://narhc.org/resources/rhc-rules-and-guidelines/

Medicare Benefit Policy Manual – Chapter 13

www.cms.gov/manuals/downloads/clm104c25.pdf

Appendix Z state operations manual

https://www.cms.gov/Medicare/.../Advanced-Copy-SOM-Appendix-Z-

EP-IGs.pdf

ECFR 491 – https://ecfr.io/Title-39/cfr491