CMS Proposed E&M Coding Changes Medicare RHC
Bill Finerfrock, Executive Director
CMS PROPOSED E&M CODING CHANGES MEDICARE RHC
Q: The information I’ve seen regarding new Medicare payment proposals includes an option to pay a flat rate (proposed fee $93). That certainly sounds like what we already have as an RHC with our AIR, and without jumping through RHC hoops. And that proposed rate is higher than the current cap for the AIR for independent RHC’s. If this goes through, what would be the point of continuing as an RHC for Medicare? I’m curious how others are viewing this proposal. Surely it would result in an increase in the cap for RHC’s.
A: It is an interesting question and one that we (NARHC) leadership and staff have discussed.
I think first and foremost would be that dropping RHC status and going to traditional Medicare fee-for-service would also mean losing the RHC Medicaid payments. I think in most instances, RHC Medicaid payments are much better than traditional Medicaid payments in most states. So depending upon your payer mix (Medicare and Medicaid) the financial gains you might realize on the Medicare side if you dropped RHC status, could be negated by the financial losses you could experience for care provided to Medicaid recipients.
Second, depending upon your staffing, the financial gains might not be as attractive as you think if you plan to continue to utilize PAs and NPs in your care model. Remember, unlike a Rural Health Clinic visit, where the Medicare/Medicaid payments are the same regardless of whether the visit is performed by a physician or a PA or NP, under traditional Medicare, the Medicare allowable is 85% of the physician fee schedule amount when the service is provided by a Physician Assistant or Nurse practitioner. So if you take the fee-for-service proposed rate of $93 for a physician and apply the 15% PA/NP the allowable would be $79.05 – less than the 2018 RHC Cap.
Finally, there may be other programs linked to your RHC status that could be having a positive impact on the financial viability of your clinic that would be lost if you gave up your RHC status.
The question you didn’t ask but that is relevant to this communication: What is NARHC doing with respect to the RHC Cap?
NARHC has long supported an increase in the Cap and continues to advocate for this change. We believe the cap should be raised to at least $115.00 – $120.00 per visit to reflect the current cost-per-visit as determined by the RHC cost reports. The HHS National Advisory Committee on Rural Health and Human Services, at the urging of NARHC, has recommended that the Trump Administration support raising the RHC Cap. The U.S. Senate Rural Caucus has previously endorsed raising the RHC cap and many individual Members of Congress have voiced their support as well.
In September, a group RHC representatives (NARHC Board and Policy Committee) from around the country will be traveling to Washington DC to meet with their elected officials to talk about the cap and other changes in the RHC program we would like to see made.
In addition, we will be reaching out to the RHC community in the next few weeks encouraging you to write to your elected representatives in Washington DC, to simultaneously support the work of those who will be on Capitol Hill doing face-to-face meetings with House and Senate offices.
NARHC is committed to getting the Rural Health Clinic Cap increased to a level that more closely approximates the cost of providing services to Medicare beneficiaries residing in rural underserved areas. Your support for our efforts is greatly appreciated.
NARHC Executive Director