establishing provider-based clinics: advanced topics · establishing provider-based clinics:...

Provider-Based Rule: Advanced Topics March 5, 2015

Florida Hospital Association 1

© 1996-2015 Abbey & Abbey, Consultants, Inc. Slide # 1

Establishing Provider-Based Clinics:

Advanced Topics

Version 12.2 - 2014

Notes © 1996-2015, Abbey & Abbey, Consultants, Inc.

CPT® Codes – © 2014-2015 AMA

Hosted By:

www.FHA.org

Presented By:

Duane C. Abbey, Ph.D., CFP

Abbey & Abbey, Consultants, [email protected] http://www.aaciweb.com

http://www.APCNow.com http://www.HIPAAMaster.com


This workshop and other material provided are designed to provide accurate and

authoritative information. The authors, presenters and sponsors have made every

reasonable effort to ensure the accuracy of the information provided in this

workshop material. However, all appropriate sources should be verified for the

correct ICD-9-CM Codes, ICD-10-CM Diagnosis Codes, ICD-10-PCS Procedure

Codes, CPT/HCPCS Codes and Revenue Center Codes. The user is ultimately

responsible for correct coding and billing.

The author and presenters are not liable and make no guarantee or warranty;

either expressed or implied, that the information compiled or presented is error-

free. All users need to verify information with the Fiscal Intermediary, Carriers,

other third party payers, and the various directives and memorandums issued by

CMS, DOJ, OIG and associated state and federal governmental agencies. The

user assumes all risk and liability with the use and/or misuse of this information.

Disclaimer




Presentation Faculty

Duane C. Abbey, Ph.D., CFP – Dr. Abbey is a healthcare consultant and educator with over 20

years of experience. He has worked with hospitals, clinics,

physicians in various specialties, home health agencies and other health care providers.

His primary work is with optimizing reimbursement under various Prospective Payment

Systems. He also works extensively with various compliance issues and performs

chargemaster reviews along with coding and billing audits.

Dr. Abbey is the President of Abbey & Abbey, Consultants, Inc. A wide range of consulting

services is provided across the country including charge master reviews, APC compliance

reviews, in-service training, physician training, and coding and billing reviews.

Dr. Abbey is the author of fourteen books on health care, including:

•“Non-Physician Providers: Guide to Coding, Billing, and Reimbursement”

•“Emergency Department: Coding, Billing and Reimbursement”, and

•“Chargemasters: Strategies to Ensure Accurate Reimbursement and Compliance”.

Recent books include: “Compliance for Coding, Billing & Reimbursement A Systematic

Approach to Developing a Comprehensive Program”, “Introduction to Healthcare

Payment Systems”, “Fee Schedule Payment Systems” and “Prospective Payment

Systems” from Taylor and Francis. He has just finished the fourth book in the Healthcare

Payment System Series; “Cost-Based, Charge-Based and Contractual Payment Systems”.


Provider-Based Clinics - Advanced

Introduction

Provider-Based Status – PBS Previously, Called Hospital-Based What Is It?

• Be Careful With Terminology Provider-Based Clinics Provider-Based Clinical ServicesGeneral Provider-Based Rule (PBR)

• General Rules Apply To Both Inpatient and Outpatient Owned, Operated and Fully Integrated With Hospital

• Criteria To Achieve Hospital (Main Provider) Includes CAHs (and Other Providers) Operational Definition Provider-based means filing a UB-04 –

Provider-based clinics file (or there is filed) both a UB-04 (CMS-1450) and a 1500 (CMS-1500)

CMS Interested Only Where There Is A Payment Differential – Clinics and Clinical Services Fall Into This Category – Application/Approval vs. Attestation

RHCs and FQHCs Are Partially Outside These Rules – 42 CFR §413.65

• Still Referred To As ‘Provider-Based’

• Special Rules

• Difficulties With APC Interface




Provider-Based Status – PBS - Continued

Freestanding Is The Opposite Of Being Provider-Based

The Provider-Based Rule Is Complex and There Is Confusion

Fundamental Terminology – ‘Facility or Organization’

• CMS is now using PBD – Provider-Based Department

Must Understand Multiple References

Cost Report Involvement

OIG Concerns

• Really Don’t Want PBS Clinics At All!

• Should Be No Payment Differential

The Emergency Department (ED) Is A Special Provider-Based ‘Clinic’

Many of the CDM concerns for general provider-based clinics are also

present for the ED

• Professional coding/billing versus technical component

coding/billing

EMTALA – Emergency Medical Treatment and Labor Act

• Creates a special set of requirements for the ED (technically the

DED or Dedicated Emergency Department)

When does a provider-based clinic become a DED?

Special EMTALA requirements for off-campus provider-based clinics.


Introduction



Introduction

Acronyms – As with other areas of healthcare organizations and

associated coding, billing and reimbursement, there are many acronyms.

PBR – Provider-Based Rule 42 CFR §415.65

PBS – Provider-Based Status

PBD – Provider-Based Department

• This terminology has been used only in the last couple of years.

EMTALA – Emergency Medical Treatment and Labor Act

ED – Emergency Department

CBR – Coding, Billing and Reimbursement

CDM – Charge Description Master or Chargemaster

SOS - Site-of-Service (Differential)

POS – Place of Service (1500 Claim Form)

MAC – Medicare Administrative Contractor

RO – Regional Office

MOB – Medical Office Building

RBRVS – Resource Based Relative Value Scale

MPFS – Medicare Physician Fee Schedule

APCs – Ambulatory Payment Classifications

RVUs – Relative Value Units




To review the Provider-Based Rule (PBR).

To understand the differences between freestanding and provider-based

clinics.

To understand the economic advantages of provider-based clinics.

To review and appreciate special requirements for provider-based clinics.

To appreciate special compliance concerns associated with provider-based

status.

To discuss coding and billing issues for provider-based clinics.

To understand how to qualify clinics that are outside the 35-mile default

limit.

To discuss signage and proper identification for provider-based

operations. To discuss complicated issues such as joint use of space and

time-share space utilization.


Objectives



Objectives

To understand provider-based reporting requirements and the CMS-855

forms.

To explore the application of the physician supervision requirement for

outpatient services.

To discuss operation issues such as setting fees, patient relations and

medical staff organizational structuring.

To review on-going ambiguities in the Provider-Based Rule affecting

provider-based operations.

To work through several case studies involving special issues in the

establishment of the provider-based clinics.

Note: This workshop assumes that participants have a basic

knowledge of the Provider-Based Rule and provider-based clinics along

with a background with the more common challenges and regulatory

requirements.




The Apex Medical Center owns and operates a family practice clinic that is

located on its campus right across the street. There is a sky-walk and

there is a large parking ramp right next to the clinic. The physicians and all

the staff personnel are employees of the hospital. Due to competitive

pressures, the only billing made is the professional component on a 1500.

Is this a provider-based clinic?

Yes?

No?

• What if this clinic meets all the PBR requirements, do we have to

file a UB-04? What about Place-of-Service on the 1500?

Is the ED at the Apex Medical Center a provider-based department (clinic)?

Yes?

No?

Maybe?

Provider-Based Clinics

Introduction - Warm-Up Exercises



Introduction - Warm-Up Exercise

Apex Medical Center Satellite Clinic

The chart shows that Apex has a split use satellite operation. Part is provider-based

and part is freestanding. Hospital personnel provide all services. Comment to all

related Provider-Based Rule concerns and including the chargemaster, cost report and

‘holding out to the public’ issues.

Reception

Apex Medical Center Satellite Clinic

Entrance

Freestanding

Clinic -

Owned &

Operated By

The Apex

Medical

Center

Hospital-

Based

Radiology

PT/OT/ST




The PBR Is Complex and There Is Confusion Several Areas Where The Rules Are Not Clear See PM A-03-030 Directions to FIs –Attestations vs. Determinations

Provider-Based Clinics 1980’s Additional Income From Both A UB-04 Technical Component and CMS-

1500 Professional Component Very Little Reduction in Payment for Professional Component – Site-Of-

Service Differential Applied To Only A Few Codes Savvy Hospitals Started Using This Organizational Concept See MAP

– Model Ambulatory Practice – Clinics Mid-1990’s – CMS (Then HCFA) Became Concerned About Proliferation of

Provider-Based Clinics Issued the Infamous PM A-96-7 (Re-Issued As PM A-99-24) 8-Criteria For Being Provider-Based Clinic Not Legislated and Not In Code of Federal Regulations Variable Guidance from Fiscal Intermediaries and Carriers Very few codes subject to physician payment reduction.

• See the implementation of the Medicare Physician Fee Schedule (MPFS) through RBRVS (Resource Based Relative Value Scale).November 24, 1991 Federal Register Entry


Provider-Based Rule – Very Brief History


April 7, 2000 – Issued New Comprehensive Rule

Note: Yes, this was issued in the APC FR Entry

The new Provider-Based Rule went beyond just considering outpatient

situations. Inpatient situations are also included to some degree.

The new PBR formalized the criteria issued in PM A-96-7.

CY2001 – CY2014

Over these years the PBR continued to evolve.

• Some degree of change has occurred almost every year.

• Some changes are explicit, while other changes are more

operational, that is, the way CMS and MACs treat certain issues.

• Example: Attestation is a process of indicating that a given

operation meets the PBR. A request for determination is a long

form requesting approval. Today attestations equal determinations.

• Example: Use of phrase ‘Provider-Based Departments’ or PBDs.

Starting in CY2008 started to make significant changes (CMS maintains

they are only clarifications).

To Understand PBR – You Must Master and Understand Multiple

References – CFR Sections, Federal Register and Associated Sources

• See AACI’s APC Website To Download Documents

www.APCNow.com/PBRInformationToolkit.htm


Provider-Based Rule – Very Brief History




Basically Eight Criteria See Famous PM A-96-7 – Repeated as A-99-24

Geographic Proximity

Integral and Subordinate Part

Under Same Accreditation

Common Ownership and Control

Day-to-Day Supervision

Clinical Services Integration

Held Out To The Public

Financial Integration

These “old” criteria where brought forward and placed in §413.65 of the

CFR

Some Changes Accreditation to Licensure (& Accreditation)

The new rules basically formalized the old rules with much more explicit

terminology.

The PBR goes well beyond directives made prior to CY2000.

The old rules addressed only ‘clinics’ while the revised PBR addresses all

departments of the hospital, both inpatient and outpatient.

Note that much discussion pertains to ‘off-campus’ clinics, but over the

years this concept has expanded to provider-based departments

(PBDs) apparently of all types.


Provider-Based Rule - “Old” Criteria



Fundamental Concepts/Analysis

Geographic Location Of Clinic

In The Hospital

• As of 2010, we have a formal definition.

Out Of The Hospital, On Campus

• Recent Physician Supervision Requirements – New Guidance

Off Campus Within 35 Miles

Off Campus More Than 35 Miles (May be able to get exception.)

Definition Of “Campus”

250 Yard Rule

May Need Special Determination By RO (Regional Office)

ZIP Code Analysis – More Than 35 Miles

75%-75% Overlap

75% Rule

Off-Campus Provider-Based Clinic Obligations

Physician Supervision See Updated Guidance & Controversy

Integrate With EMTALA

Patient Notice Of Two Co-Payments

• Slight Change August 12, 2005 FR Entry If Only One Co-Payment

vs. Two Co-Payments




Licensure

Licensure Is A State Level Process

State Level Idiosyncrasies – See Also Certification

Licensure versus Accreditation

Operation Under Ownership and Control of Main Provider

100% Ownership See 3-Day Pre-Admission Window (Wholly Owned

or Operated)

Main Provider – Final Administrative Responsibility

Administration and Supervision

Clinical Services

Professional Staff – Same Privileges

Medical Director

Medical Staff Organization

Medical Records – Integrated (Cross Referenced)

Financial Integration

Tax Identification Numbers – Accounting Purposes?

National Provider Identifiers? See CMS-855 Forms–Billing Privileges

Public Awareness Patients must know entering hospital.

Location In Immediate Vicinity


PBR - Qualifying For PBS


Provider-Based Status

EMTALA Changes For Off-Campus

• New Definition – “Dedicated Emergency Department”

• Off-Campus Without DED – “Call 911” versus Working With Main

Provider ED

Inappropriate Treatment as Provider-Based

• Inappropriate Billing

• Good Faith Effort

• What Are The Penalties?

Physician Supervision Changes

• Definitions and Requirements – Off-Campus vs. On-Campus

• Mid-Levels – Non-Physician Practitioners – Recognition as

Supervisors

Other Changes

• Joint Ventures – Acceptable For On-Campus

• Management Contracts – Acceptable For On-Campus

• Under Arrangements – Never Changed or Explained (!)

What does the under arrangement prohibition mean?


PBR – On-Going Changes




Qualifying and Application/Attestation This Involves Determination of Provider-Based Status Situations Such

As Clinics and Other Activities

Prohibitions Prohibitions Can Apply To Any and All Hospital Activities

Obligations Obligations Can Apply To Any and All Hospital Activities

Reporting Report Any ‘Material Changes’ Relationship to CMS-855 Reporting

• Updating Attestation Forms (?)

These four items must be considered for a wide range of circumstances.


PBR - Overall Analysis Template



Provider-Based Clinics - Billing

Split Billing – Chargemaster Issue

1500 + UB-04

Only Required To Split-Bill Medicare

What About Other Third-Party Payers?

What About Secondary Payers

• Split-Bill Medicare Primary ONLY??

How To Set Fees

• Take Current Physician Fee Schedule & Divide?

• Medicare Charging Rule - Compliance

• Example

Current Physician Fee = $80.00

New Physician Fee = $60.00

Technical Component = $20.00

Any Problems?

o Physician Fee

o Technical Component Fee

• Note: We are making certain to bill all patients the same amount.

Notice of Two Co-Payments

• What must be done to meet this requirement for off-campus

clinics?





Setting Fees Exercise

Case Study/Exercise – Setting Fees - The Apex Medical Center is in the

midst of converting a freestanding clinic into a provider-based clinic.

Based upon bad publicity generated from other conversions in the general

region, Apex is very sensitive to keeping the overall fee structure the same,

but splitting the current fee into two parts:

Professional Component Must be higher than that which would be

paid by MPFS

Facility Component Can be a small amount but must be greater than

the APC co-payment amount for the given code.

• Discuss how you would go about constructing such a split fee

schedule.

• Do you think that you will have any problems?

• Will the example given on the preceding slide work?

See the July, 2007 issue of AACI’s Medical Reimbursement Newsletter

for a more complete article. Electronic subscription is free of charge.



Setting Fees Exercise

Split Fee Schedule Example

* The 20% coinsurance is used, the National Unadjusted co-payment is $37.01.

CPT Full Prof

Fee

Split

Prof Fee

Medicare

Pay

Split

Tech Fee

APC Pay APC*

CoPay

99201 $59.00 $35.00 $22.00 $24.00 $92.53 $18.51

99202 $103.00 $62.00 $42.00 $41.00 $92.53 $18.51

99203 $149.00 $89.00 $63.00 $60.00 $92.53 $18.51

99204 $232.00 $139.00 $107.00 $93.00 $92.53 $18.51

99205 $294.00 $176.00 $139.00 $118.00 $92.53 $18.51

99211 $30.00 $18.00 $9.00 $12.00 $92.53 $18.51

99212 $59.00 $35.00 $22.00 $24.00 $92.53 $18.51

99213 $100.00 $60.00 $43.00 $40.00 $92.53 $18.51

99214 $151.00 $91.00 $66.00 $60.00 $92.53 $18.51

99215 $204.00 $122.00 $93.00 $82.00 $92.53 $18.51





Location and Space Considerations

Shared Space Situations

Many Different Situations Can Arise

The main concern is that of signage and ‘holding out to the public’.

Patients must know that they have entered hospital ‘property’.

• For off-campus situations, see special EMTALA requirements.

Space may be:

• Owned

• Rented/Leased

• Time-Shared

Each situation will need careful assessment so that the MAC/RO will

accept the attestations and/or approve the request for determination.

• Careful attention must be given to cost reporting implications.

• Consider the shared space at the Satellite Clinic described on Slide

# 10.




Case Study/Exercise – Split-Use Building - The Apex Medical Center has

established a provider-based clinic about 20 miles from the hospital. They

are renting space in a nice building that has an entrance with a long

hallway that splits the building into two parts. The clinic is on the left while

on the right is a real estate agency.

Discuss signage issues.

• How will the patient know they are on hospital property?

What about accreditation?

Are there going to be any local/state regulations?

Will the MAC/RO question this type of arrangement?

• What kind of documentation can you develop to justify that

provider-based requirements are being met?






Case Study/Exercise – MOB - There is a Medical Office Building right next

to the Apex Medical Center. There is a skywalk between the two buildings.

Part of the offices in the building are rented by physicians who have

private (i.e., freestanding) practices. Several of the offices are slated to

become provider-based clinics.

Should there be any concern about signage in this type of case?

What about the main directory in the lobby?

What about signage for the individual offices that are part of the

hospital?

What kind of EMTALA policy should be established?




Case Study/Exercise – Time-Share Arrangements – Two specialists are

employed by Apex. Each of them are in different specialty that is in very

short supply in the local area. There is a smaller hospital about 25 miles

away. Each of these specialists spends one day a week at the smaller

hospital. One on Tuesdays and one on Thursdays. Each of these two

physicians provide services in a nice specialty clinic of the smaller

hospital. While the same set of examination rooms are used by each of the

two specialists, the registration and front-desk staff are provided by the

smaller hospital. Apex wants the operation for the two physicians to be

provider-based to Apex (not the smaller hospital).

Is this feasible?

What will need to be accomplished relative to signage and holding-out

to the public?

What about licensing and accreditation?

Will there be any cost-report challenges?






Case Study/Exercise – Cardiologists Inside MOB - A group of cardiologist

has joined forces with the Apex Medical Center. The hospital has allocated

one-half of one floor of a Medical Office Building for the clinic. The

physician services, that is, evaluation and management, will be conducted

as a freestanding operation. The cardiologist will do their own

documentation and billing in addition to having clinical staff (i.e., nurses,

medical assistants). However, all the technical services (e.g., treadmills,

stress tests, EKGs, Holter monitors, etc.) will be performed in the same

general area only these will be under the purview of the hospital. That is,

the hospital will be billing for all these technical services as a facility.

What concerns to you have about this kind of an arrangement?

How are patients going to know that they have left the physician clinic

and are now in a hospital (facility) area?



Physician Supervision

April 7, 2000 Federal Register, Page 18525 (65 FR 18525)

“We emphasize that our proposed amendment of § 410.27 to require

direct supervision of hospital services furnished incident to a physician

service to outpatients applies to services furnished at an entity that is

located off the campus of a hospital that we designate as having

provider-based status as a department of a hospital in accordance with

the provisions of § 413.65. Our proposed amendment of § 410.27 to

require direct supervision of hospital services furnished incident to a

physician service to outpatients does not apply to services furnished in

a department of a hospital that is located on the campus of that

hospital.”

• This is the language that CMS claims that healthcare providers have

‘misinterpreted’. Questions started arising in CY2008.


Diagnostic

Therapeutic






Diagnostic Testing

Diagnostic testing supervision involves three levels of supervisions:

• General,

• Direct, and

• Personal.

“For CY 2010, we are finalizing the proposal to require that all hospital

outpatient diagnostic services provided directly or under arrangement,

whether provided in the hospital, in a PBD of a hospital, or at a

nonhospital location, follow the physician supervision requirements for

individual tests as listed in the MPFS Relative Value File.” (74 FR

60591)

• Note: Mid-levels are not allowed to meet the diagnostic testing

supervisory requirement. They can provide the services, but are

not allowed to supervise the conduct of the services.

Does this make any sense??




Therapeutic Services

To What Services Does Physician Supervision Apply?

• CMS started with ‘incident-to physician’ services.

This addresses most services

• CMS has moved on to more limited categories of services as well.

See Radiation Oncology

What are the basic requirements for ‘direct physician supervision’?

• Physician/Practitioner must be interruptible.

• Physician/Practitioner must be immediately available.

• Physician/Practitioner must be able to take over care, not just

address emergencies.

What kind of documentation should be maintained?

What is special about cardiac rehab, pulmonary rehab and intensive

cardiac rehab?

• “For pulmonary rehabilitation, cardiac rehabilitation, and intensive

cardiac rehabilitation services, direct supervision must be

furnished by a doctor or medicine or osteopathy as specified in

§§410.47 and 410.49, respectively.” (Page 72008 – 75 FR 72008)






Therapeutic Services

CMS Minimum Supervisory Standard

• “Direct supervision is the minimum standard for supervision of all

Medicare hospital outpatient therapeutic services. Considering that

hospitals furnish a wide array of very complex outpatient services

and procedures, including surgical procedures, CMS would expect

that hospitals already have the credentialing procedures, bylaws,

and other policies in place to ensure that hospital outpatient

services furnished to Medicare beneficiaries are being provided

only by qualified practitioners in accordance with all applicable

laws and regulations. For services not furnished directly by a

physician or nonphysician practitioner, CMS would expect that

these hospital bylaws and policies would ensure that the

therapeutic services are being supervised in a manner

commensurate with their complexity, including personal

supervision where appropriate.” (Transmittal 128 to Publication 100-

02 Medicare Benefits Policy Manual May 28, 2010)



Conversion of Clinics

Case Study/Exercise – Conversion of Clinics - This is a group of

oncologists who have established several infusion centers in the general

area. The farthest is 21 miles away. The plan is for the hospital to

purchase the infusion centers and then employ the oncology group. The

oncologists basically want the infusion centers to operate as they have in

the past. All of the employees are to be retained. It turns out that the

fringe benefits for the infusions centers is actually better than for the

hospital (more generous retirement, more vacation days, and better health

coverage). The oncologists want the reporting relationships in this

operation to remain the same. They, the oncologists want to do the hiring,

firing and direction of employees. The physicians have a very good

professional billing system that they want to retain. (Note that there are

significant 340b considerations.)

Are there any compliance concerns from the PBR that relate to this

kind of an arrangement.

What is the proper way to handle this kind of a challenge.





Outside 35 Mile Default Limit

Case Study/Exercise – Infusion Centers - Consider the oncology infusion

centers described in the preceding slide. Let us change the scenario

slightly. In this case we will assume five infusion centers. However, one of

the centers is slightly outside the 35-mile default limit. Unfortunately, both

of the ZIP statistical exceptions also fail. Both the hospital and the

oncologists want all of these operations to be provider-based.

Discuss what Apex can do.

Is it possible to get approval from the MAC/RO when the 35-mile limit is

violated?

What kind of an argument would you make to convince the MAC/RO to

allow the one outlier clinic to be provider-based.



Clinic Inside Hospital

Case Study/Exercise – Physicians Inside Hospital - Apex has hired two

relatively expensive cardiovascular physicians. These two physicians will

be housed in an area of the hospital designed for physicians with several

sets of examination rooms along with a reception area. The physicians

want this operation to be freestanding. The main concern is the two co-

payment situation for Medicare beneficiaries.

Can Apex have a freestanding clinic inside the hospital?

How will patients know that this clinic is not part of the hospital?

Are there any cost-report implications?

Do physicians (or actually their employer the hospital) have to pay rent

at fair market value?





Case Studies and Exercises

Case Study/Exercise – Physician Office Laboratory – The Apex Medical

Center developed a freestanding clinic several years ago. This clinic is

located about 20 miles from the hospital. The clinic has grown

significantly over the years. There are about 25 physicians of different

specialties. This is also a ‘Physician Office Laboratory’ at the clinic with a

drawing station to collect various samples. This laboratory also provides

services for other physician clinics in the area. Apex now wants to convert

this clinic to provider-based status.

Outline the steps that will be necessary for conversion.

What about the physician office laboratory?

• Will this laboratory create any complications?

• Will there be CLIA (Clinical Laboratory Improvement Act)

considerations.

• Should this physician office laboratory be discontinued with only

waived tests performed at the clinic?



SNF Provider-Based Clinic

Case Study/Exercise – SNF Provider-Based Clinic - The Summit Nursing

Home is a skilled nursing facility that has grown over the years and now

has almost 200 residents. Summit has difficulty getting physicians to

come to their site to provide services to the residents either on a

scheduled basis or on an urgent basis. Thus, Summit has decided to

develop their own provider-based clinic and staff the clinic with a physician

and two mid-level practitioners.

Can Summit establish a provider-based clinic?

Where is this clinic going to be located?

Are there any unusual PBR considerations?

Are there any special payment issues relative to SNF reimbursement?





Medicare Enrollment

Medicare Enrollment for Provider-Based Clinics

There are six different CMS-855 forms.

• CMS-855-A Part A Hospitals

• CMS-855-B Part B Clinics

• CMS-855-I Individuals – Physicians/Practitioners

• CMS-855-O Ordering Referring

• CMS-855-R Reassignment

• CMS-855-S DME

Additional Decisions that Are Required Relative to Enrolling in Medicare

Organizational Structuring

Tax Identification Numbers

NPIs – National Provider Identification Numbers

Which forms are of interest for hospitals relative to provider-based clinics

and operations?

CMS-855-B for the clinic or group of clinics.

CMS-855-I and CMS855-R for the physicians at the clinics.

CMS-855-O for physicians who do not otherwise bill Medicare.

CMS-855-A for the hospital to address issues such as practice

locations because the provider-based clinics are part of the hospital.



Medicare Enrollment

Case Study/Exercise – (From the CMS-855-B Workshop) - Apex is a small

integrated delivery system. While many different services are provided,

among the providers are the following:

Home Health Agency DBA Aspire Home Health,

A Skilled Nursing Facility DBA the Summit Nursing Home,

Three freestanding clinics all DBA Center Clinics, and

Three provider-based clinics all DBA Family Practice Associates.

• All of these organizations are wholly owned and operated by the

Apex Medical Center. There is a single TIN for everything. Apex did

obtain separate NPIs for each of these four organizational

structures as subparts. All of the physicians along with non-

physician practitioners (NPPs) are employed by the hospital (i.e.,

Apex Medical Center).

Apex also has a DME company located off the main lobby.

Discuss this arrangement relative to NPIs, TINs, and CMS-855-A and

CMS-855-B.

• Who should be handling this?

• Assuming 35 physicians and NPPs, how many 855 forms will there

be? (Consider the CMS-855-I, 855-R and possibly the 855-O.)





CMS-855-B Section 2C – Identifying Information



CMS-855-B Section 2C – Identifying Information

Section 2C must be correlated back to the CMS-855-A for hospital.

This information was previously requested on the CMS-855-A.





Attestations and Determinations

Attestations versus Requests for Determination

Note: Technically, hospitals do not have to do anything other than meet

the requirements in the PBR. Thus, hospitals are not required to use

attestations or determinations, as such. There is no official form.

See PM A-03-030

Initially in 2003 -

• The idea was for hospitals to file a simple attestation indicating

compliance with the PBR.

• For off-campus clinics, a full determination was required and

extensive forms were developed to gain approval.

Today – Circumstances and Requirements Have Morphed

• The concept of attestations has really become what was used to be

requests for determination.

• Long forms are used as attestations in order to gain approval from

the MAC/RO.

• There are even hints that attestation can be updated to report

changes. (Will this meet the reporting requirement under PBR?)

See the AACI website, www.APCNow.com/PBRInformationToolkit.htm, for

examples of the attestation form from different MACs.



Attestations and Determinations

Filing Attestations

The current attestation forms are quite lengthy and detailed.

Basically, the requirements under the PBR are delineated.

• Sometimes there are simply ‘yes-no’ questions

Example – For off-campus clinics, do you have an EMTALA

policy approved by the hospital board?

• Often additional documentation is required.

Example – Organizational charts showing reporting

relationships in order to verify that the given operation is truly

a part of the hospital.

• Special Efforts May be Necessary

Example – Providing photographs of the signage at off-campus

clinics.

• Exercise – Discuss what would be required to file attestations for

the Apex Medical Center if there were five different clinics being

established or converted. Assume that all are off-campus.




Case Study/Exercise – HBO Clinic - The Apex Medical Center has

contracted with an outside company to provide Hyperbaric Oxygen (HBO)

services. AMC is providing space in a building several blocks from the

hospital. The outside company is providing the equipment, supplies, a

physician, nursing and technical staff. Apex is providing clerical staff for

registration, billing, etc. Apex pays the outside company for the services,

and then Apex files claims with third-party payers including Medicare.

How does the Provider-Base Rule come into play in this situation?

Are there any supervisory issues?


Under Arrangements



3-Day Pre-Admission Window

Case Study/Exercise – The Apex Medical Center has more than a dozen

provider-based clinics. There is one outlying clinic where many

complaints have been made concerning the two co-payments. Thus, Apex

is now studying moving this particular clinic back to freestanding, that is,

wholly owned freestanding.

Discuss this overall process and include any concerns about the 3-Day

Pre-Admission Window.





The Future of Provider-Based Clinics

Will the increased overall payment for provider-based clinics continue on

into the future?

OIG – Wants the payment differential done away; payment should be

the same for freestanding clinics as for provider-based clinics.

MedPAC – Recommendation to eliminate payment differential for E/M

services.

CMS Comments from December 10, 2013 Federal Register:

“We stated in the CY 2014 OPPS/ASC and MPFS proposed rules that in

order to better understand the growing trend toward hospital

acquisition of physician offices and subsequent treatment of those

locations as off-campus provider-based outpatient departments, we

were considering collecting information that would allow us to analyze

the frequency, type, and payment of services furnished in off-campus

provider-based hospital departments.” (Page 761 CMS-1601-FC)

• Potential Methods for Data

New POS for Off-Campus Provider-Based Clinics

HCPCS Modifier to Indicate Provider-Based Clinic (PO Modifier)

Separate Cost Center on Hospital Cost Report



Summary & Conclusions

Understand The Terminology and Concepts

Freestanding Clinic

Provider-Based Clinic

Significant Economic Advantage To Hospitals That Own and Operate

Clinics To Make Them Provider-Based

Medicare Site-of-Service Differential Concept – Physician Payment

Reduction – No Overhead

Physician Reduction More Than Made Up By Technical Component

Payment, That Is APCs

Cost-Benefit Analysis

• Tangibles versus Intangibles

• Properly Assessing Costs

Operational Challenges

Proper Place of Service (POS) Coding Is Critical

Chargemaster Setup

Form Follow Function

Professional vs. Technical Component Coding

E/M Levels Along With Surgical/Medical Services

Split Billing Issues – Establishing a Proper Fee Schedule




Provider-Based Rules and Regulations Application/Approval versus Attestation Process Provider-Based Services versus Provider-Based Clinical Services

• Provider-Based Clinics – Separately Recognizable• Provider-Based Clinical Services – Generally On An Ad Hoc Basis –

Generally Not Separately Recognizable Units• Economic Advantages

Obligations Prohibitions Reporting – Material Changes Planning – Payment Differential Will Probably Be Available For 5 to 7

Years (?) – It will be phased out over time although the increased payments are continuing for the time being.

There Are A Number Of Special Situations and Concerns Other Issues

EMTALA Interface for Off-Campus Provider-Based Clinics Physician Supervision Requirements – See Provider-Based

Departments Medicare Enrollment–CMS-855-A, 855-B, 855-I, 855-R, and maybe 855-O

• See Also NPIs and TIN Issues Non-Physician Practitioners Issues 3-Day Payment Window


Summary & Conclusion