(Medicare Benefit Policy Manual)

80.2 - RHC and FQHC Consolidated Cost Reports  (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23)  RHCs  and FQHCs  with  more  than one site may file consolidated cost reports if  approved by the A/B MAC in advance of the reporting period for which the consolidated report is to be used. Once having elected to use a consolidated cost report, the RHC or FQHC may  not revert to  individual reporting without the prior approval of the A/B MAC.  New RHCs (enrolled under section 1866(j) of the Act on or after January 1, 2021) are permitted to file consolidated cost reports with:   New RHCs that are provider-based,  New RHCs that are independent,  Existing independent RHCs, and/or  Existing provider-based RHCs that are in a hospital that has more than 50 beds. In addition, specified provider-based RHCs are not allowed to file a consolidated cost report with a new RHC.  80.3  RHC and FQHC Cost Report Forms  (Rev. 11803; Issued: 01-26- 23; Effective: 01 -01-23; Implementation: 02-27-23)   RHCs  and FQHCs  use one of the following  cost report forms:  Independent RHCs and  Freestanding FQHCs:  RHCs: Form CMS -222- 17, Independent Rural Health Clinic Cost Report.  FQHCs:  Form  CMS -224-14, Federally  Qualified  Health  Center  Cost Report.  Provider- based  RHCs  and FQHCs:   Hospital- based RHCs : Worksheet M of Form CMS-2552-10, Hospital and Hospital Care Complex Cost Report.  Hospital-based FQHCs: Worksheet N of Form CMS-2552-10, Hospital and Hospital Care Complex Cost Report.  Skilled Nursing Facility based: Worksheet I series of form CMS-2540-10, Skilled Nursing Facility and Skilled Nursing Facility Health Care Complex Cost Report.   Information on these cost report forms is found in Chapters 44 and 46; and 40 and 41,  respectively, of the Provider Reimbursement Manual - Part 2 (Publication 15-2), which can be located  on the CMS Website at http://www.cms.gov/Regulations-and- Guidance/Guidance/Manuals/Paper -Based -Manuals.html .    the patients  condition without the interposition  of a third  persons judgment. Direct  visualization  includes review  of the patients  X-rays,  EKGs,  tissue  samples, etc.   Except for services that meet the criteria for authorized care management or virtual  communications services, telephone or electronic communication between a physician  and a patient,  or between  a physician  and someone on behalf of a patient,  are considered physicians services and are included in an otherwise billable visit. They do not constitute  a separately  billable  visit.   Qualified services furnished at an RHC or FQHC or other authorized site by an RHC or FQHC physician are payable only to the RHC or FQHC. RHC and FQHC physicians are paid according  to their  employment agreement or contract  (where  applicable).   80.4  RHC Productivity Standards  (Rev.239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Productivity standards are used to help determine the average cost per patient for Medicare reimbursement in RHCs.  The current productivity standards require 4,200 visits per full- time equivalent physician and 2,100 visits per full-time equivalent non- physician practitioner (NP, PA, or CNM).  Physician and non-physician practitioner productivity may be combined.  The FTE on the cost report for providers is the time spent seeing patients or scheduled to see patients and does not inc lude administrative time.  The A/B MAC has the discretion to make an exception to the productivity standards based on individual circumstances.  All visits (Medicare, Medicaid, Managed Care, etc.) are included in determining the productivity standards for the cost report. At the end of the cost reporting year, the A/B MAC re- calculates the AIR by dividing the total allowable costs across all patient types (i.e., the numerator) by the number of visits (as defined in section 40) for all patient types (i.e., the denominator).  If fewer than expected visits based on the productivity standards have been furnished, the A/B MAC substitutes the expected number of visits for the denominator and uses that instead of the actual number of visits.  The total allowable cos ts (numerator) would be divided by the higher, expected number of visits (denominator).  In this example, this would have the effect of lowering the AIR. Physician services that are provided on a short term or irregular basis under agreements are not subject to the productivity standards.  Instead of the productivity limitation, purchased physician services are subject to a limitation on what Medicare would otherwise pay for the services under the Physician Fee Schedule (PFS), in accordance with 42 CFR 405.2468(d)(2)(v) .  Practitioners working on a regular, ongoing basis are subject to the productivity standards, regardless of whether they are paid as an employee or independent contractor.  FQHCs are not subject to the productivity standards.  90 - RHC and FQHC Charges, Coinsurance, Deductible, and Waivers  (Rev. 252, Issued: 12-07-18, Effective: 01-01-19, Implem entation: 01 - 02-19) Except for certain preventive services for which the coinsurance is statutorily waived, the beneficiary in an RHC must pay the deductible and coinsurance amount, and the beneficiary in an FQHC must pay the coinsurance amount (there is no Part B deductible in FQHCs for FQHC -covered services).  For RHCs, the coinsurance is 20 percent of the total charges.  For FQHCs, the coinsurance is 20 percent of the lesser of the FQHCs charge for the specific payment code or the PPS rate.  For claims  with a mix of waived and non- waived services, applicable coinsurance and deductibles are assessed only on the non-waived services.  For both RHCs and FQHCs, coinsurance for care management and virtual communication services is 20 percent of the lesser of submitted charges or the payment rate.   90.1 - Charges and Waivers  (Rev. 220, Issued: 01-15-16, Effective: 02-01-16, Implementation: 02-01-16)   Charges for services furnished to Medicare beneficiaries must be the same as the charges for non-Medicare beneficiaries.  FQHCs may waive collection of all or part of the copayment, depending on the beneficiarys ability to pay.  RHCs may waive the copayment and deductible after a good faith determination has been made that the patient is in financial need, provided the waivers are not routine and not advertised.  (See 42 U.S.C. 1320a- 7a(6)(A))  90.2 - Sliding Fee Scale  (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  RHCs may establish a sliding fee scale if it is uniformly applied to all patients.  An RHC that chooses to offer a sliding fee scale must post the policy so that all patients are aware of the policy.  If the payment policy is based on an individuals income, the RHC must document that income information from the patient was obtained in order to determine that the patient qualified.  Copies of their wage statement or income tax return are not required, and self -attestations are acceptable.  FQHCs that are approved by HRSA are required to establish a sliding fee scale in accordance with statutory and HRSA requirements.   100  Commingling  (Rev. 239, Issued: 01-09-18, Effective: 1-22-18, Implementation: 1-22-18)  Commingling refers to the sharing of RHC or FQHC space, staff (employed or contracted), supplies, equipment, and/or other resources with an onsite Medicare Part B or Medi caid fee-for-service practice operated by the same RHC or FQHC physician(s) and/or non- physician(s) practitioners.  Commingling is prohibited in order to prevent:    Duplicate Medicare or Medicaid reimbursement (including situations where the RHC or FQHC is  unable to distinguish its actual costs from those that are reimbursed on a fee-for-service basis), or    Selectively choosing a higher or lower reimbursement rate for the services.  RHC and FQHC practitioners may not furnish or separately bill for RHC or F QHC -covered professional services as a Part B provider in the RHC or FQHC, or in an area outside of the certified RHC or FQHC space such as a treatment room adjacent to the RHC or FQHC, during RHC or FQHC hours of operation.  If an RHC or FQHC practitioner furnishes an RHC or FQHC service at the RHC or FQHC during RHC or FQHC hours, the service must be billed as an RHC or FQHC service.  The service cannot be carved out of the cost report and billed to Part B. If an RHC or FQHC is located in the same building  with another entity such as an unaffiliated medical practice, x -ray and lab facility, dental clinic, emergency room, etc., the RHC or FQHC space must be clearly defined.  If the RHC or FQHC leases space to another entity, all costs associated with the lea sed space must be carved out of the cost report.   RHCs and FQHCs that share resources (e.g., waiting room, telephones, receptionist, etc.) with another entity must maintain accurate records to assure that all costs claimed for Medicare reimbursement are on ly for the RHC or FQHC staff, space, or other resources.  Any shared staff, space, or other resources must be allocated appropriately between RHC or FQHC and non-RHC or non- FQHC usage to avoid duplicate reimbursement.  This commingling policy does not prohi bit a provider -based RHC from sharing its health care practitioners with the hospital emergency department in an emergency, or prohibit an RHC practitioner from providing on- call services for an emergency room, as long as the RHC would continue to meet the  RHC conditions for coverage even if the practitioner were absent from the facility.  The RHC must be able to allocate appropriately the practitioner's salary between RHC and non- RHC time.  It is expected that the sharing of the practitioner with the hospital emergency department would not be a common occurrence.  The A/B MAC has the authority to determine acceptable accounting methods for allocation of costs between the RHC or FQHC and another entity.  In some situations, the practitioners employment agree ment will provide a useful tool to help determine appropriate accounting.   110 - Physician Services (Rev. 252, Issued: 12- 07-18, Effective: 01- 01-19, Implementation: 01-  02-19) The term physician includes a doctor of medicine, osteopathy, dental surgery, dental medicine, podiatry, optometry, or chiropractic who is licensed and practicing within the licensees scope of practice, and meets other requirements as specified.   Physi cian services are professional services furnished by a physician to an RHC or FQHC patient and include diagnosis, therapy, surgery, and consultation.  The physician must either examine the patient in person or be able to visualize directly some aspect of t he patients condition without the interposition of a third persons judgment.  Direct visualization includes review of the patients X -rays, EKGs, tissue samples, etc.   Except for services that meet the criteria for authorized care management or virtual communications services, telephone or electronic communication between a physician and a patient, or between a physician and someone on behalf of a patient, are considered physicians services and are included in an otherwise billable visit.  They do not c onstitute a separately billable visit.  Qualified services furnished at an RHC or FQHC or other authorized site by an RHC or FQHC physician are payable only to the RHC or FQHC.  RHC and FQHC physicians are paid according to their employment agreement or contract (where applicable).