Description:-

Hospitals are increasingly establishing provider-based clinics of all types.  The provider-based rule (PBR) is complex, and there are definite ambiguities.  While hospitals can enjoy increased revenues from provider-based clinics, compliance with all the rules and regulations is challenging.  Recent changes in the supervisory requirements for provider-based operations have created confusion and new compliance challenges.

Additionally, with Section 603 of the Bipartisan Budget Act of 2015, there is the movement to change the rules and regulations relative to reimbursement for provider-based clinics.  In this workshop, the overall purpose and function of the provider-based rule is addressed as well as critical information concerning physician supervisory changes along with a discussion of the future of provider-based clinics.  Particular attention is made to rule changes as implemented by CMS relative to Section 603 of BBA 2015 and further changes made by Section 16001 of the 21st Century Cures Act.  Update information from the CY2018 and CY2019 OPPS and MPFS update Federal Registers will be discussed.

Teleconference/Webinar Objectives:- 

• To briefly review the Provider-Based Rule (PBR).
• To review the criteria that must be achieved for clinics to be recognized as provider-based.
• To update the current status of changes in payment to off-campus provider-based clinics as provided through Section 603 of the BBA 2015.
• To review the further changes made by the 21st Century Cures Act.
• To briefly update critical physician supervisory rule changes.
• To discuss documentation requirements relative to physician supervision requirements.
• To appreciate the increase in reimbursement for provider-based clinics.
• To understand the attestation and request for determination processes.
• To understand the need for updating and the documentation of organizational structuring relative to the PBR.
• To understand the review/audit process for assessing current and/or potential provider-based situations.
• To understand the economic benefits versus the compliance requirements.
• To appreciate the relationship of PBR relative to the Conditions for Payment, Conditions of Participation and gaining billing privileges.
• To understand the regulatory pressures for reducing reimbursement for provider-based clinics.
• To appreciate the evolving guidance that is being provided by CMS and the Regional Offices.
• To work through several case studies.

Teleconference/Webinar Outline/Agenda:-

• Review of the Provider-Based Rule (PBR)
  • Development of the PBR
  • 42 CFR §413.65
  • Review of Definitions
  • Rules and Regulations
  • Recognition by Non-Medicare Third-Party Payers
  • Very Brief History of Provider-Based Clinics
• Economic Advantages of Provider-Based Status
  • Clinics
  • Clinical Services
  • Costs for Provider-Based Status
• Current Activity Surrounding Medicare Payment for Provider-Based Clinics
  • OIG Recommendations
  • MedPAC Recommendations
  • CMS Data Gathering of Cost for Off-Campus Provider-Based Clinics/Operations
    • PO Modifier – UB-04
    • POS 19/22 Indicators - 1500
• • Section 603, BBA 2015 Changes Starting January 1, 2017
    • Final Rules for 2017
    • Payment Processor Non-Excepted Clinics
    • Special Issues
  • Section 16001, 21st Century Cures Act
    • Definition of ‘New’ Relative to BBA 2015
    • Mid-Build Exception for Grandfathering
  • CY2018 & CY2019 OPPS Federal Register – Policy Changes
  • CY2018 & CY2019 MPFS Federal Register – Payment Processes
• Provider-Based Requirements – Special Issues
  • Signage and Recognition
  • EMTALA Interface
  • Notice of Two Copayments
  • Split-Billing
  • Shared Space Concerns
  • Co-Location Issues
  • Under Arrangements
  • Other Regional Office Issues
• Physician Supervisory Requirements
  • Recent Changes and Clarifications
  • Relationship to Physician Incident-To Billing
• Provider-Based Audits
  • Process
  • Data Gathering and Assessment
  • Attestations and Requests for Determination
  • Action Steps
• Provider-Based Clinics – The Future
• Case Studies – Provider-Based Clinics

Prerequisites for Participating:- 

General knowledge of hospitals and various clinic and clinical operations.

Suggested Attendees:- 

All personnel involved with the provider-based clinic and clinical operations, compliance personnel, coding and billing personnel, nursing staff and interested physicians are encouraged to attend.

Description:-

Approximately one-third of all Medicare beneficiaries are enrolled in various Medicare Advantage programs. These plans are generally offered by insurance companies and tend to be regional.  The key descriptor for these programs is that of variability. Each of these programs must cover what traditional Medicare covers, but they then generally expand from this basic coverage and add services such as dental, drugs, eyeglasses along with possibly expanded coverage for medical and surgical services. In some cases the costs of these programs is less than traditional Medicare.

Medicare Advantage (MA) programs represent some real challenges for healthcare providers such as physicians, hospitals, skilled nursing, home health among others. In some cases a given provider will be part of a network or under contract to the given MA plan, and thus coding, billing and reimbursement are governed by the contract between the provider and the MA program. In other cases, a given healthcare provider may be filing a claim with an MA plan across the country in which there is no relationship between the MA plan and the provider.

Three different perspectives are discussed in this workshop:

• Medicare beneficiary to the MA plans,
• Providers coding, billing and reimbursement relative to MA plans,
• Medicare’s relationship and compliance relative to MA organizations.

For this program, emphasis is given to provider relationships particularly for physicians and hospitals. If a claim is filed by a healthcare provider that is not part of the MA plan’s network, then the claim is to be adjudicated under the traditional Medicare rules. Given the variability in coverage and medical policies, there can be confusion when claims are adjudicated and paid.

Possible expansion of telehealth benefits as listed in the November 1, 2018 Federal Register will also be discussed.

• What is Medicare Advantage?
• What are the different kinds of MA programs?
• Why are Medicare beneficiaries interested in the MA programs?
• What kinds of services are covered by MA programs?
• Do physicians and hospitals contract with MA organizations?
• How do MA programs pay for services of physicians, hospitals and other healthcare providers?
• What if a physician or hospital is not contracted with a MA program?
• What kind of appeal processes are available when physicians and hospitals disagree on payment or coverage?
• How does Medicare view these MA programs?
• What is this risk adjustment process?
• What kind of compliance issues are there with MA programs?
• How is the CMS expanding telehealth services for MA programs?

Teleconference/Webinar Objectives:-

• To understand Medicare Advantage programs work.
• To appreciate the different forms and formats of MA programs.
• To appreciate why the MA programs are so popular with Medicare beneficiaries.
• To understand how physicians, hospitals and other healthcare providers contract with and become part of networks.
• To appreciate the process of filing claims to MA programs with which the provider has not relationship.
• To understand how claims are adjudicated and payment is made for both contracted and non-contracted situations.
• To appreciate the appeals process when there are coverage and/or payment disagreements.
• To understand how the Medicare program views Medicare Advantage.
• To explore compliance issues surrounding payment to MA organizations.
• To review expansion of telehealth services for MA programs.

Teleconference/Webinar Outline/Agenda:- 

• Medicare Advantage Overview
  • How The MA Programs Work
  • Different Kinds of MA Programs
  • How Payment Is Made
  • Contracted Providers
  • Risk Adjustment
• Medicare Beneficiaries and MA Programs
  • Coverage Concerns
  • Hospice Coverage
  • Cost-Benefit Analysis
  • MA Program Termination
• Healthcare Provider Relations
  • Physicians and Hospitals Contracting with MA Programs
  • Contracted Providers Filing Claims with MA Programs
  • Non-Contract Providers Filing Claims with MA Programs
  • Appeals Process for Disagreements
  • Claims Adjudication and Claims Payment
  • Primary Care Versus Specialized Services
  • Special MA Program Concerns
    • Hospice
    • Medicare Secondary
  • Special Coverages
• Medicare Perspective With MA Programs
  • Risk Adjustment Process
  • Payment by Medicare to MA Programs
  • Compliance Concerns and Audits
  • Expansion of Telehealth for MA Programs
  • RAC Involvement
• Sources For Further Information

Prerequisites for Participating:- 

General knowledge of healthcare providers including physicians, clinics, and hospitals.

Suggested Attendees:- 

Managed Care Analysts, Compliance Officers, Compliance Analysts, RAC Coordinators, Clinical Directors/Managers, Physicians, Practitioners, Nurses, Information Technology Personnel, Computer Analysts, Health Information Management Personnel, Chargemaster Coordinators, Revenue Cycle Specialists, and Internal Auditors