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[Music].good afternoon everyone and welcome to.today's event hosted by region 8 chapter.of HF MA today's webinar is titled.provide base billing it really is rocket.science I would like to welcome today's.guest presenter Linda Corley Linda is.the VP of compliance for extend.healthcare Linda has worked.collaboratively with hospitals and.physician offices for the past 25 years.Linda served as controller of the.university-owned for hospital group.while providing insight to clinical and.financial staff members on compliant.reimbursement when des is a coder in a.frequent hsm a presenter with over 15.years of experience leading CDM reviews.coding and billing audits and providing.consulting services for revenue cycle.improvement without further delay I will.turn it over to our presenter presenter.Linda please go ahead thank you and good.afternoon everyone.I'm delighted to be here with you to.talk about provider based billing thank.you for joining us so as we begin today.I will let you know that this is a very.information packed presentation some of.the slides I will just touch on briefly.because I believe a lot of this.information is basic and you will.probably already know that but then I'll.go into some of the new developments.regarding particularly off-campus.provider-based clinics so as we begin.this afternoon I always like to start.with information regarding the acronyms.that may be included within this.presentation most of these I remember.but sometimes when I'm viewing.information I simply want to have a.legend or some definitions that I can go.back to that let you know what all the.acronyms stand for for today's.presentation I wanted to mention briefly.why provider based status is so popular.and why we are seeing more and more.requests for.provider-based departments are clinics.of hospitals talk about new audit and.oog emphasis on provider based services.talk about some identified operating and.then billing errors that we certainly.want to discuss how to correct those and.and truly just look at this provider.based Amin because I think there are.lots of definitions out there and as is.often the case with healthcare we have.several different terms that refer to.similar services within our healthcare.environment there are some CMS provider.based definitions that I want to be sure.that you have talked about the guidance.of how to become a provider base to.service area and then what obligations.come with that provider based status.certainly some good reimbursement in.some cases and then understanding what.your obligations may be back in 2012 we.did have the new requirement of.including three-day payment windows.services within when we roll our.services for that three-day window into.our inpatient claim we certainly now.have new requirements for including some.of those outpatient provider based.services both professional and facility.or technical services provider based.payment review I think the biggest.question for us all is does it always.mean increased cash when we are able to.change to that provider based status and.then of course in compliance is.extremely important to all of us not.only do we want to qualify for perhaps.increased cash but we want to be sure.that we are compliant with our processes.to earn that cash so that we can keep it.once we do receive it so why many why so.many questions about provider based.services I do think because of the.number of independent physicians and of.course entire practices that are.becoming hospital employed certainly.that has brought provider based for more.to the forefront of how services are.being provided many hospitals do prefer.to qualify for provider based status.because reimbursement is often but not.always higher than freestanding.physician certainly hospital outpatient.services through APCs which are.ambulatory payment classifications are.paid at a higher rate than the usual.Medicare physician fee schedule the.hospital is able to include their.provider based cost on the Medicare cost.report so that is also a benefit of.provider based status however looking.past or looking back over the past five.to seven years we do know that CMS has.been concerned regarding a significant.number of our hospitals who are falling.short of what is mandated for provider.based status and we're going to discuss.some of those mandates the OIG for the.past four years has listed provider.based non-compliance as one of its top.concerns and I have worked with several.hospitals just over the past two years.who have had their provider based status.reviewed and the OIG does continue to.audit the services that are being billed.as provider based to make sure all of.the mandates for providing the services.how they are charged and built to.patients and the reimbursement received.those audits are ongoing to ensure.compliance and if we look at both the.current administration and certainly the.past administration for CMS has been.actively expanding their use of payment.recapture audits in all of our federal.reimbursement programs provider based if.I just had to give an opinion I would.put at the very top of those audits as.far as being paid appropriately the.Joint Commission back several years ago.did survey a Midwest hospital operating.as a provider based clinic during that.evaluation the accrediting.organization determined there was a lack.of medical record integration between.the hospital and the clinic as result.the Commission did fight the hospital.for deficiencies and of course that's.part of what today's presentation is all.about not only do we want to be able to.build provider based services.appropriately but we want to ensure all.of those individual requirements for.provider based are being consistently.followed and that consistent word is.extremely important I think generally.when we are reviewing or when we are.focused focusing on a particular area of.operations and billing certainly we take.the time to review and ensure that.appropriate procedures are in place.however I think you will agree.provider-based takes a little more.attention perhaps auditing on a monthly.basis to ensure the information or data.being billed on our claims is.appropriate for where the services were.provided and how those services were.carried out the biggest error that we.have seen in the past according to CMS.this place of service coding errors now.they call them coding which I know it is.a code for place of service but a lot of.times I see these place of service.errors coming from the billing office in.the past these were undetected because.we had a different fiscal intermediary.processing our part a hospital claims.from that Part B agent I think we.generally call them or carrier we had.two different groups processing our.claims for payment so the errors were.not as evident however now as all of you.know we have changed to a single the.Medicare administrative contractor that.processes and pays both facility or.technical component claims as well as.professional claims so they are.certainly easy to bump up against each.other and see.what discrepancies are there if the.hospital operates a physician clinic as.a provider based clinic Medicare.determines that it does not meet.provider based criteria of course there.will be fines and recruitments of any.inappropriate payments that have been.made regulation 42 CFR defines what.operations are identified as a Medicare.certified provider for provider based.versus with suppliers such as DME.durable medical equipment this.particular regulation does determine.what hospital services can be billed.under the Medicare provider number as.provider based so when we look at an.individual provider we know that CMS or.Medicare identifies separate hospitals.critical access hospitals skilled.nursing facilities home health hospice.course FQHCs and then CMHC's so all of.these different types of providers are.identified by Medicare and as you know.just to confuse ourselves sometimes we.refer to physicians and or even other.clinicians and therapists as providers.however in this case for provider based.service CMS does define the provider as.the hospital a provider based location.or site means it is simply part of the.hospital and our services are being.billed as hospital outpatient services.we want to be careful of course with the.word clinic because we have various.interpretations I think we use clinic.because of some of the clinics that we.have traditionally referred to like a.wound care clinic or some of the others.that we name however keep in mind that.we're going to utilize provider based to.prefer to refer to the type of services.being provided that are part.of the hospital outpatient service group.the particular regulation that does.define provider based status is not.applicable to these and that's why we do.not talk about provider based services.for these listed different types of.providers and I won't read those to you.you can see those there however based on.these exclusions the provider based.statue effectively only applies to.hospital outpatient departments and.rural health clinics remember a provider.based entity does have a separate.different provider number however a.provider based location such as we are.referring to hospital outpatient or.hospital clinic has the same provider.number as the hospital itself and I.think that's an important differentiator.to keep in mind these are just.definitions that I pulled from that CMS.regulations so that you would have them.as part of your resource the main.provider of course for provider based.services is the hospital that creates or.acquires another location to deliver.additional services in its name Campus.refers to that physical area of main.buildings of the hospital or within 250.yards a department of a provider could.be a facility organ or excuse me an.organization that is owned or acquired.by the main provider to offer medical.services or clinical services in its.name.certainly a provider based location must.be identified through signage and.communication efforts in the very same.way as part of the main provider so our.marketing materials registration forms.and other registration materials how the.phone is listed websites all have to.refer to the hospital itself looking at.a provider based entity may be a set.currently certified provider owned by.the main provider and this is the.traditional hospital based concept so if.I look at a skilled nursing facility.that's going to be a provider based.entity on its own separate from the.hospital itself we do have some remote.locations of hospitals which would.simply be another site that furnishes.inpatient hospital services and then if.we move away from all of those and look.at a free-standing facility that is an.entity that is not provider based not.owned by a hospital and also not run or.the services are not carried out as.hospital services campus gets a lot of.discussion these days as you will see.the reason why we are concerned about on.campus locations versus off-campus the.physical area immediately adjacent to.the hospital or the providers main.buildings in all of the other areas and.structure structures that are not.strictly contiguous to the main.buildings but are located within 250.yards all of this is important for.defining how provider based services not.only are going to be built but also how.they are going to be reimbursed as we.will discuss a department of a provider.of course we talk often about radiology.laboratory and of course now we can.recognize that provider based area of.services as a department and as as I.mentioned before the licensed for a.provider based department is the same as.that for the hospital the department is.not licensed to provide healthcare.services in its own right and is not by.itself qualified to participate in.Medicare as a provider it is part of.that main provider the hospital with.which it is connected.medicare conditions of participation do.not apply to a department as an.independent entity and that is important.at times because a problem with a.particular department or provider based.clinic can cause a review by Medicare.regarding whether or not the hospital is.meeting their conditions of partition.participation all of that is tied.together freestanding as I mentioned.that is an entity or a service area that.furnishes healthcare services to.Medicare beneficiaries and is not.integrated with any other entity as a.main provider it's not our department of.a provider it's not a remote location of.a hospital and it is not a provider.based entity it is simply a different.type of ownership standing on its own to.serve Medicare beneficiaries the main.provider of course is that hospital that.either creates or acquires ownership of.another entity to deliver additional.health care services under its name.certainly under its ownership and under.its financial and administrative control.so when we get down to the actual.definition of a provider based entity.that is a provider of healthcare.services that is either created by or.acquired di'ja main hospital provider.for the purpose of furnishing healthcare.services that are different from those.of the main provider under named.ownership and administrative and.financial control of that main provider.as we have talked about more definitions.and some of these I'll leave just for.you to read a universal provider based.department must meet these particular.CMS require requirements common.licensure for both if that is allowed by.state law certainly financial.integration is there at the top of the.list and in financial integration is one.of those areas that CMS and the OIG has.been reviewing in the last audits of say.the last two to three years financial.must be included in the hospital trial.balance this is the provider based.services that we are talking about must.be included in the allowable cost.centers on the Medicare cost report same.as any other hospital department and.then clinical integration is also high.on the list the provider based area or.department must have the same clinical.oversight as any hospital department and.that means they must have the same.medical director Quality Assurance must.be carried out in the same manner or.using the same policies and procedure.certainly utilization review all of the.clinical review must be carried on the.same for the provider based area or.department or clinic as is for the.hospital medical records and this one.has become more important to us there.must be either a unified retrieval.system or a system that is able to be.crossed referenced so that charts for.the provider based area are readily.available at all locations the medical.staff of the hospital must have clinical.proof privileges at the provider based.site or facility off campus is a little.bit different and we will continue to.bring out what is different about off.campus and how off campus sites have.been affected by legislation or by.regulatory requirements in both 2016 and.2017 there must be required management.contract terms so that the providers.control is clear policies and procedures.written the same and carried out the.same and that's why I mentioned that.word consistency to you again the.provider must employ all non management.staff members who provide patient care.excluding those that can separately bill.under their own provide.number such as a physician or a.mid-level the management and leadership.employees must follow provider policies.those of the hospital managers policies.must be approved by the hospital.provider.there must be periodic written recall or.it's required to the provider from the.provider based area and then on-site.staff members must be subject to the.provider or the hospital's approval so.all of these refer to the hospitals.off-campus sites for provider based.services they also must meet that same.common ownership same legal entity and.governing body administration and.supervision the same as any other.provider based department Human.Resources all of those service areas.that you see there must be the structure.must be the same and they must be.carried out for hospital the same as for.hospital employees and as we know that.off-campus providers site must be.located within 35 miles of the main.provider or meet a market share test.certainly management contract rules will.apply and then joint ventures for.provider based services are not allowed.or they are prohibited other.requirements we do know that a provider.based clinic may be on the hospital's.main campus or within 35 miles to.qualify for off-campus must operate.under the main providers the hospital's.license as we mentioned unless the state.requires a different licensure the.provider based clinic must have ready.access to the hospitals and other.providers clinics medical records very.important and then physicians and staff.operating within the provider based.clinic or area are under the same.reporting structure as all other.hospital departments the provider based.clinic or outpatient department must be.incorporated into the hospital's.organizational chart and I wanted to.include all of these.as a review and as a resource so you.will see all of the operational.requirements that continue on for both.on-campus and off-campus provider-based.clinics even though we're going to talk.about different payment methodologies.for us off campus more requirements the.directors and the managers for that.provider-based area must be involved in.the same meetings as their peers in.other hospital departments we mentioned.hospital privileges must be granted to.the professional staff for the provider.based department or area the support.staff must receive the same in-service.training as the clinical support staff.of the hospital hospital policies on.infection control safety disaster plans.all of those hospital or main provider.operating policies and procedures must.be not only part of the provider based.operating system but must be.consistently addressed we mentioned.signage certainly an important audit.area for that provider based clinic as.we are finding out from the audits we.mentioned the provider based clinic or.area must be on the hospital's trial.balance as a separately identifiable.cost center must use the same charge.description as the hospital in other.words the charge structure for services.must be the same for hospital outpatient.services as it will be in that provider.based service area Medicare patients.must be registered at hospital patients.and I can't say that enough if you are.operating a hospital based service area.department or clinic your Medicare.patients must be registered as hospital.outpatients so what has changed place of.service I mentioned that to you.primarily because in the past CMS and.the OIG.have.identified errors on how professional.service and claims are being filled out.or submitted I should say and as you.know we're billing those professional.services on a CMS 1500 claim form if you.are billing Medicare for those.professional service and you are in or.you are billing provider based services.you would not use place of service 1111.is only for office based or.free-standing physician services we.either must use for Medicare place of.service 22 which is a hospital on campus.outpatient service area or 19 place of.service which is a hospital off campus.outpatient service area and as.previously mentioned all terms of the.Medicare provider agreement which.generally we see in the hospital's.conditions of participation must be.carried out a deficiency at any site.will jeopardize the entire hospital.provider status so that's an important.one to us to be sure that we are.bringing in all of our hospital based.provider service areas to be part of our.provider agreement to meet the.conditions of participation.non-discrimination provisions certainly.are applicable to physicians and an.Impala becomes an important obligation.if our provider based services are on.campus EMTALA will apply as part of the.hospital if our provider based services.are off-campus.EMTALA will only apply if that service.area is held out as urgent care or if.greater than one-third of our patient.visits are unscheduled so I always like.to bring up in.because I have seen a hospital penalized.in the past two years for not meeting.their EMTALA obligations in an on-campus.provider based service area to go back.to those off-campus departments for 2016.CNS or Medicare did implement new coding.and billing guidance for new modifiers.for provider based claims other than.rural health clinics and of course I've.already mentioned to you the new place.of service code for those 1500 or.professional claims Keogh modifier.should be appended to every hickspicks.code on the facility claim this new.place of service code 19 also will be.shown on those professional claims for.auth patient outpatient hospital.provider based services we will continue.to use place of service code 22 for.on-campus outpatient services for 2017.we did have the new ruling or regulatory.information that only accepted.off-campus provider-based apartments or.clinics will continue to be paid under.outpatient prospective payment now what.is accepted nning those provider based.areas that were operating and building.as off-campus provider-based apartments.before November 2nd 2015 are accepted.and will still be paid under OPP s you.can include as accepted those that were.under development but not yet billing.and those who had submitted a voluntary.provider based.attestation before December 2nd of 2015.those were grandfathered in.there were also some mid build out of.stations for provider-based areas under.construction during the first quarter of.2017 but the important information on.this particular slide to me is you.either have an accepted off-campus.provider-based location if it was.operating and billing before November.2nd 2015 or you have met the under.development but not yet billing or you.had already submitted your voluntary.provider based attestation before.December 2nd of 2015 provider based.off-campus locations as we will see.started last year being paid differently.and that has continued for provider.based off-campus locations for 2018 to.look again at what obligations are there.you must treat all Medicare patients as.hospital patients with the facility or.technical component of the services.billed on a ubo for inpatients of the.hospital as I mentioned to you the.three-day payment window does apply for.that facility component for services in.provider based entities and we added to.that and all diagnostic and related.therapeutic professional components so.let me say that one to you again if you.are charging and billing Medicare for a.provider based clinic or hospital.outpatient department not only must you.include your facility components of.services provided within the three-day.we used to call it 72-hour window but.now you must also include on your.inpatient claim any diagnostic and.related therapeutic professional.components that were charged and billed.during that three-day window off-campus.sites must provide notice of dual.coinsurance and that would be for the.facility technical component and for the.professional component to each Medicare.patient before services are provided.unless it is an emergent service so.off-campus sites must provide notice to.that Medicare beneficiary of dual.coinsurance being charged and collected.to each Medicare patient before the.services are provided so to restate the.obvious that I've spent a lot of time.saying we're going to use the very same.CPT for or hickspicks level 2 codes to.bill our physician services provided in.an independent freestanding clinic or in.a provider based clinic we don't have.separate codes for the services so both.the physician.professional services and the provider.based clinic technical or sometimes we.call those the facilities services are.going to be built using the same CPT and.hickspicks level 2 codes because these.are outpatient services as we know CMS.does pay a greater dollar amount in an.independent physician office but they.pay less for the physician component in.a provider based clinic and I'm sure.many of you have looked at that.professional see what we call the.Medicare physician fee schedule and that.particular list of services shows a.particular dollar amount to reimburse.the physician for his or her services if.provided in their own independent what.we call free-standing office and that is.a larger or greater amount then when we.look at what the physician will be paid.in a hospital outpatient area of service.such as the provider based clinic.however when we change to our provider.based clinic our outpatient department.services now Medicare is also paying a.separate dollar amount for the related.APC ambulatory payment classification.which is the facility or the technical.component that we will be along ub-04.what we call a hospital or facility.claim CMS has been and continues to be.understandably concerned that it does.not pay for an individual APC on the.hospital ubo for claim and then also pay.the non facility or higher rate for the.professional cpt for code on that CMS.1500 claim.and I think again this is very obvious.but it's difficult to remember when.these claims are either being.established in your billing system to.appropriately charge and bill for the.services and then of course we want to.be sure that place of service is.correctly identified on your 1,500 claim.so that the physician component or.professional component is appropriately.paid the lesser amount we have found or.just my years of working with particular.hospitals and physician practices.billers are generally either.knowledgeable about Part B physician.payment and claims in other words.they're used to billing services on a.1500 or they are Hospital billers.billing on a ubo for for Part A services.however a lot of times they do not know.both and that's where I think education.and certainly spot audits so that you.can reassure yourself these claims are.going out the door correctly so that.you're being paid compliantly or.appropriately for provider based service.Part B Bueller's generally are.accustomed to identifying the correct.service provision on a claim by using.modifiers and if you will just keep in.mind on that Part B claim the.professional 1500 claim generally we are.going to identify a technical component.or we're going to use modifier 26 for a.professional component extremely.important but split billing a physician.office visit for a provider based clinic.is not really similar to billing a.procedure or a diagnostic service with.one of those modifiers either TC or 26.we have no modifiers equivalent to that.26 profession.and TC technical that would allow the.provider to indicate to Medicare whether.it is billing globally or whether it is.split billing the professional component.and the technical component so we are.submitting both a split bill both a 1500.for the professional service and a ubo 4.for the technical or facility component.so when we change to our provider based.status for outpatient departments and.clinics I Bueller's must be.knowledgeable about place of service 22.on campus place of service 19 off campus.for that 1,500 claim form we generally.recommend if you are a physician.changing to provider based status we.would not want to not only educate our.billing staff but all departmental staff.members about how this is a different.payment methodology particularly our.professional services are being paid.based on different requirements and.different types of services so that.there's good understanding throughout.charge capture billing reimbursement.even appealing denials turns out to be.just a little bit different for provider.based services so we want lots of.training in in detail information.regarding place of service the only way.Medicare can make certain the particular.CPT code is being paid appropriately is.based on that place of service and I.apologize for for nagging about that but.I do still still see lots of errors when.we are working with clients and based on.the audits that I've looked at in the.past couple of years hospitals still.have difficulty getting place of service.correct and we know that we.never ever ever want to build Medicare.for a provider based outpatient service.area using place of service 11 on that.professional or 1500 claim I get a lot.of questions about out of stations about.provider based status the application.for a provider based entity or.pre-approval by CMS is still not.required that Code of Federal.Regulations 42 that I mentioned to you.now says may submit the attestation.that's to notify CMS of any provider.based locations the hospital does state.that applicable requirements have been.met and the hospital at that point.attests to meeting the obligations for.provider based operations also we may.use that attestation to notify CMS of.any material changes regarding how.hospital outpatient services are being.provided the attestation of provider.based status and meaning the.requirements is voluntary and medicare.continues or CMS continues to give us.that information her Medicare or CMS.provider based operations depend on the.hospital's self monitoring process and.then of course I had to add until that.provider based area outpatient.department or clinic is audited.extremely important that we understand.what the requirements are and that they.are being consistently followed there is.no official at a station form that has.been published there is a sample format.in Medicare or CMS transmittal zero.three zero three zero that was issued.back on April 18th of 2003 you are.instructed or we are instructed to send.that attestation form to the Medicare.administrative contractor that is.process.in your claims and then you would also.send a copy to the CMS regional office.for on-campus supporting documentation.is not required but is recommended and.then if you are opening an off-campus.location supporting documentation is.required the Medicare administrative.contractor or the Mac may make a.determination of whether it's approved.or whether it's accepted is probably the.word that they would use the regional.office should either approve or.disapprove.now we generally recommend that out of.stations be completed that the sample.format be used because I think this.draws your attention to whether or not.you are meeting the requirements for a.provider provider-based location what.are the benefits of submitting the.attestation if you have submitted that.attestation and it has been accepted or.approved by the regional office then CMS.would only recoup any excess payment if.later that provider-based area is found.non-compliant in other words what that.is saying to us is that there would not.be any fines we may have to pay back the.money that we were paid inappropriately.or non-compliant lis but we would not be.assessed to fine certainly as I.mentioned it does trigger a good self.review off the criteria that must be met.providers excuse me it does that the.attestation does provide written support.that not only have you reviewed what's.required for a compliant process but.that you are attesting to that process.being followed and that you are.attaining that compliant process it does.educate the staff when they are involved.in preparing the attestation it educates.all that are involved with what is.required and then we do know that that.particular regulation does say that we.must evaluate the.requirements and determine the legality.of provider-based so having that.attestation carried out submitting it.does attest to the fact that we have.gone through that review certainly.Medicare or CMS continues to remind us.that a particular area outpatient.department our clinic is not provider.based just because the hospital believes.that area to be so I will say again we.recommend filing that attestation to.meet compliant foundation for the.services that you are charging and.billing to Medicare as provider based.what are the financial reasons for.filing that provider based attestation.if the regional office of CMS does.accept as I mentioned it will limit.recruitment if the facility is later.determined out of compliance without a.reviewed at a station on file CMS can.recoup as far back as the applicable.statue of limitations which is generally.about seven years that's what I've been.able to find out if a subsequent review.determines that criteria were not met.the additional money reimbursed due to.billing this provider based of course.will be recouped now provider based.reimbursement we all are interested in.for our hospital outpatient areas.because we generally believe it to be.greater than freestanding physician.services the amount of or even any.increased revenue is not automatic.however and here are the things that.even CMS tells us to review to be sure.that we are going to receive increased.revenue based on providing these.provider based services look at.specialty or type of clinical services.to be provided particularly look at your.payer mix the greater the Medicare.percentage of payers.of course the higher likelihood that.provider-based will be greater.reimbursed the volume of services are.being provided in this particular area.or outpatient department and then.whether or not you are in a rural versus.urban setting CMS does recommend case.specific analysis for each area or.entity you would want to compare current.physician fee schedule that Medicare.physician fee schedule payments to.hospital based outpatient prospective.payment system which of course are paid.under APCs.certainly look at the additional cost.for the technical component versus the.physician professional component only.and then review facility RV use so some.in-depth analysis is needed before any.new decision to move to provider based.and certainly on campus provider based.is much more attractive these days than.off-campus provider based because of the.recent 2016 2017 regulatory changes but.an in-depth review of your payer mix.particularly the services you are.providing how those are being reimbursed.if you have a free-standing physician.clinic let's say how are those being.reimbursed in the Medicare physician fee.schedule and how will you be reimbursed.as a provider based on campus outpatient.area.mostly reimbursement does result in.increased cash outcome I'm almost.reluctant to even say that to you.because there are so many factors that.affect what you will be paid from.Medicare under your provider based.status versus what you would continue to.be paid based on a free-standing.physician arrangement under outpatient.prospective payment or that otps I've.mentioned to you the ambulatory payment.classifications usually pay more than.the fee schedule however you do need.that comparison of procedure based.specialists we want to be sure that that.comparison does reveal provider based.payment to be greater than the Medicare.physician fee schedule however we say.that they usually pay more than APCs.generally pay more because it reflects.historical reliance on Medicare or CMS.building in to APCs 24/7 365 day.operations being carried out by the.hospital and that building and equipment.investment is generally higher or more.costly thus those APCs.reinforce reimbursed more than the.Medicare physician fee schedule.certainly reimbursement can increase at.a greater percentage for critical access.hospital provider based entities now.notice that all of this says.historically so again I would stress to.you if you are considering a new.on-campus provider based outpatient.department area or clinic or other.services just be sure you're putting in.enough time and energy and effort into a.review of the to reimbursement methods.now I.have prepared the Medicare reimbursement.for a level 3 physician office visit for.2018 notice this is I think these are.Iowa rates but this is just an example.please look at your specific services.being provided and the reimbursement you.are currently receiving versus what you.would receive through an APC payment so.in a free-standing physician clinic now.this is just four nine nine two and.three the physician would be paid sixty.eight dollars and twenty twenty-one.cents excuse me by Medicare in a.provider based clinic because we are.able to bill as you know both the.professional component which would pay.forty eight twenty nine and look at how.I mentioned to you that 48:29 because.this service by the physician is being.provided in a hospital outpatient area.it is less than what the physician would.be paid in his or her own clinic so 4829.for the professional component but then.medicare and medicare only keep that in.nine will also reimburse the APC for.that nine nine two one three ninety.dollars and ninety four cents then you.would end up with a hundred and thirty.nine dollar payment from Medicare for a.provider based on campus location versus.sixty eight dot 21 cents in a.free-standing physician clinic.provider-based rural health clinic owned.by a hospital with less than 25 beds is.exempt from the per visit reimbursement.cap which is good the difference the.difference depends on the allowable cost.of that rural health clinic and those.cost include cost allocated from the.hospital now as I mentioned to you.please keep in mind these are national.payment rates yours may and probably.will vary so this is just an example of.a CPT code by CPT code analysis that you.should carry out and I want to add to.this particular slide also we know that.for that outpatient prospective payment.and APCs we have new considerations for.this year because of Medicare bundling.of outpatient services so even if you.have a provider based on campus clinic.you probably want to look at your claim.examples regarding how they will now be.paid by Medicare because Medicare has.included so many comprehensive APCs I.think Medicare has 62 comprehensive APCs.for this year and those comprehensive a.pcs may affect how your provider based.on campus service area is being.reimbursed extremely important why would.anyone not want to operate a provider.based clinic oftentimes I meet with.physicians and they will ask me you know.Linda this looks like it's too good to.be true why would you not want to go to.an on-campus provider based service area.and and here's just a couple of things.that I've been able to come to our.conclusions I've reached the reason.Medicare pays more is because it does.cost more to operate a provider based.location that is part of your hospital.operation.that a free-standing physician clinic.think about all the requirements I've.taken what 20 or 25 minutes to share.with you just what the operational the.clinical service area all of the.additional requirements that you will.have to meet the regulations for.provider based that you do not have for.a free-standing physician service area.in return for increased reimbursement.Medicare requires increased regulatory.compliance including a decreased.acceptance of fraudulent billing more.oog audits more Mac audits and I think.we will see even more this year because.CMS and the OIG have focused on provider.based status particularly on campus if.you have an off-campus location please.do some spot audits every month to make.sure that your off-campus provider based.facility claims have the appropriate.place of service have the appropriate.modifier and all billing regulations are.being carried out you don't have to do.all that many claims but if you've got.off-campus provider based just look at.five on a monthly basis to be sure the.billing regulations and the compliance.regulations for operating that.off-campus provider basis location those.regulations are being followed I have.talked with lots of physicians.particularly those who were in an.independent practice prior to working in.a provider based site sometimes even at.the same location they have simply.either sold or the hospital has acquired.their particular practice physicians of.course are not always enthusiastic about.all of this additional regulatory.oversight and that Medicare at some.point is going to.the services that are being charged and.build it can seem or some hospitals will.even say to me that they have proven to.themselves that provider based services.are more trouble and cost more than the.increased revenue coming from Medicare.and most of the time I see that when.Medicare is a very small percentage of.their payer mix so as I mentioned to you.the greater your percentage of Medicare.patients the more provider based may be.may result to you in increased.reimbursement I've also noticed this.bottom bullet that I think is.interesting the increased reimbursement.often leads to increased expectations.regarding physician compensation so I.have had doctors say to me the hospital.is being paid more for services now.because we are a provider based clinic.and that physician himself or herself is.interested in how they are being paid.for the services they are providing so.you want to be sure you've discussed how.does Medicare reimbursement in the.provider based location area fit within.the organization's existing physician.compensation arrangements so that's just.a heads up to look at if you are a.hospital considering provider based.services that you make sure you.understand how your physicians are.looking to be paid themselves what's the.other or what I think is the number one.drawback with provider based is that a.significant portion of that increase.particularly in your cash may be.inpatient copay or patient.responsibility portion of the charge and.again keep in mind that if you are split.billing for provider based locations.then you are sending two claims to.Medicare one on a 1500 claim form for.the profession.component on which that Medicare.beneficiary is going to owe a copay and.then you're also sending a ubo for for.the hospital services on which the.Medicare beneficiary will a copay so 20%.of the hospital facility or technical.charge for government payer patients and.actually when we look for Medicare.beneficiaries if you will look at.addendum B you will see there the.national coinsurance rate and we are.finding for 2018 that that amount is.actually greater than 20% but it is.changed every year because CMS or.Medicare calculates the the payment rate.for APCs.and then sets the coinsurance amount.individually for that particular CPT.code and of course 20% of the physician.fee schedule or the allowable amount for.the professional component so your.Medicare beneficiaries who are who.received services in a provider based.outpatient area will be billed.- coinsurance amounts.you.as you see they are considered the.possible negative effect of that.Medicare patient being responsible for.two co-pays or two coinsurance amounts.some Medicare beneficiaries of course.will have a secondary insurance policy.that will pay for that copay or.coinsurance but you just want to be.aware of how to handle any negative.effect of that Medicare beneficiary by.being asked to make or to pay two.co-pays we do call this sometimes split.billing for Medicare we're separating.the hospital component for the service.from the professional component.submitting to Medicare claims for the.same patient for the same data service.for the same services as we've discussed.the hospital facility or technical.component billed on the ubo for the.professional component built on that CMS.1500 unless a critical access hospital.elects to have all-inclusive payment.bills the same as traditional hospital.based physicians in the emergency.department radiology.that's just to give you an idea of what.the 1500 or the professional claim will.look like private pay here is a big.question on provider based whether you.are going to bill or not bill commercial.and provide excuse me commercial and.private payers as provider based what.Medicare our CMS regulates or tells us.that all Medicare patients must be.billed as hospital outpatients.however the CMS regional office has.confirmed that this does not apply to.Medicare Advantage plans you know those.are the Medicare HMO policies and.Medicare secondary so the only payer.that you must split bill is Medicare.traditional.private pay point-of-care payment for.provider based services by the patient.may be significantly higher now that's.what we've said on that previous slide.when you look at the how you are going.to charge and bill provider based.services so you want to have scripts so.that not only can this be explained to.patients but so that your staff members.or your team members can answer the.questions that come up you do have to.provider based billing choices you may.split bill all services to all payers.using the same two charges and notice.that this may you may split bill all.services to all payers one for the.facility component one for the.professional component you may also.adjust off the charge for commercial.insurance if that payer does not.recognize 510 or that clinic revenue.code for the facility component now of.course we see this every day if I look.at a particular private or commercial.payer they are generally used to seeing.a professional claim only for that.office visit that I mentioned to you.that cpt code nine and two one three so.now if you are going to send a facility.component ubo for claim for that five.ten revenue code for the facility.component you may know that your.particular commercial payer does not.recognize that as a reimbursable charge.I have you know provider-based clinics.that use this particular methodology.however the CMS guideline says that we.only must split bill Medicare and you.may establish a third global charge for.your private or commercial payers.Medicare does allow hospitals to build.private and commercial insurance.excuse me insurers as freestanding.even if the Medicare type of service is.provider based so I will mention that.one again you can continue to build your.private or commercial payer with whom.you have a contract that outlines how.you are going to be paid for your.services if it does not allow a.technical component for that office.visit and evaluation then you can.continue to build commercial and private.payers as freestanding it is Medicare.that we must bill as hospital outpatient.and we would have two claims going to.Medicare now again I have a slight.example and I apologize I know I'm.running over our time but I will try to.be quick this is strictly for.illustration only your payment will be.different but some hospitals have shown.me this methodology in order to be able.to bill the same dollar amount of charge.to all patients but to either bill your.freestanding clinic claim on a 1500 for.your private and commercial payers but.then also follow the regulation and Bill.Medicare appropriately with two claims.so if we look at that level three nine.nine two and three we see in a.free-standing clinic.example only your charge could be $300.we see what Medicare would allow what.Medicare would pay and what the copay.would be however for a provider based.clinic we see splitting that 300 hundred.excuse me $300 charge into a.professional component and a facility.component what Medicare would allow and.then what you would be paid from.Medicare keep in mind.illustration only your payment amounts.will be different and again I will say.keep in mind 2018 a PC packaging because.the other services charged and build on.your Medicare claims will have an effect.on this reimbursement.okay benefits certainly being able to.build drugs 340b is important some of.the others I won't read those to you.because I am over time you do as I.mentioned to you if you are considering.a new location you want to be sure that.you report it to your Mac within that.particular effective date of change you.would use that CMS form 855 which is.just the enrollment form and you see.some information there that will help.you to be sure that your provider based.attestation is filed appropriately for.any new compliance requirements I get.the question two hospitals have to.employ physicians in the provider based.clinic no as long as your physician will.follow all the rules and billing.requirements for Medicare using that.position excuse me using that place of.service twenty-two or nineteen if you're.in an off campus it does work and all.other split billing situations let's see.and by that I mean that physicians are.able to Bill and other split billing if.you have a radiologist interpreting the.film or the image then of course he or.she is going to build their own.professional service but you want to be.sure if you are not employing the.physicians and you are not in charge of.how their claims are being submitted to.Medicare you want to be doing audits so.that you know they are compliant I do.say there if the physician is not.employed it does increase the risk that.patients will be treated as private.patients of the doctor and not admitted.to the hospital outpatient service as is.required so that's one that you want to.have control of remember EMTALA we.mentioned those requirements for.particularly for on campus and then for.off-campus depending on the services.being.I did the question I get most often of.course is provider-based status worth it.it completely depends on your particular.payer mix services being provided.services charged and build on the claim.and how they are being reimbursed so I.suggested you do need to perform your.due diligence excuse me.due diligence of reviewing this year's.Medicare coverage of services payment.methodologies and billing requirements I.do recommend that you follow any.provider based service location follow.those claims being submitted very.closely again you don't have to do huge.audits just do enough audits so that you.know what is being billed on the claim.has the appropriate coding I say never.take for granted you know what.information is being submitted on your.Medicare claims just because I work with.hospitals that are so surprised after.some Medicare or OIG audits and we find.information that is incorrect you do.want to look at your payment receipt.closely to make sure you are being paid.appropriately if your billing on campus.to provider based remember your cost.reporting requirements and then that.annual review each January because.Medicare outpatient prospective payment.changes so we did make it again I.apologize for being late Christine do.you have questions that I need to answer.now we have a couple questions and still.a lot of listeners so if you are able to.answer about three or four questions I.think sure okay awesome.so our first one is a billing commercial.payer the same as Medicare I think that.that question it almost has to be.answered for individual location you do.not have to bill your commercial and.private payers the.you build Medicare because Medicare.requires that split billing or two.claims and there are some questions out.there regarding how the professional.component what we see a lot of times I.think this this question is referring to.what we see a lot of times is a patient.will be seen in a provider based clinic.and then that patient will be sent to.hospital outpatient for a particular.perhaps a more complicated imaging.service or sometimes a procedure so the.provider based clinic claim for a.Medicare provider must be billed in the.two claims but again if that patient.presents to hospital outpatient not in.the provider based clinic those services.are going to be billed as they generally.are remember Medicare require there's.service location to be shown on a claim.and where the service is provided is.what determines how those services are.going to be charged and billed so the.provider based clinic services would be.billed according to the rules we've.talked about today the hospital.outpatient service would be charged and.billed as we normally would if my.patient goes to the hospital outpatient.area for let's say an MRI that MRI is.going to be built on a hospital.outpatient claim separate from the.provider based clinic and the.professional service would then be built.on a 1500 but both would be reimbursed.according to the guidelines that we know.for hospital outpatient areas okay.another question what is coinsurance for.off-campus clinic.what is coinsurance for off-campus.clinics Medicare has come up with an.alternative reimbursement methodology.for off-campus and we would need to.bring up those amounts and look at each.individual CPT code to understand what.that coinsurance is going to be it was.stated.that it would be 20% of the allowable.payment but as you know CMS continues to.change what coinsurance how it's.calculated and and what it is and let me.say this I have up the final slide of.the presentation it has my email address.anyone that wants to send me particular.questions or if you want to just have an.individual telephone conversation I will.be glad to do that and find additional.information for you and send it to you.so send me an email I will find the.amounts for you and we can work on where.you where you can locate those or where.you can see exactly the amounts but it's.going to be individually different now.based on the Medicare physician fee.schedule okay another question is it.possible to carve out any specific.services or codes and then build those.as freestanding while still billing.others as PB not to Medicare everything.must be billed as PB to Medicare but yes.if you look at specific services for.your private or commercial payers you.can build those just about any way you.choose to bill now I have to go back to.the CMS or the Medicare requirement that.we've had for years and years that every.patient must be treated the same lately.that has been interpreted more that.patients do not have to be billed the.same but they must receive the same.services so while I think the answer is.for Medicare know if you are providing.services in a recognized on-campus.provider based service area then all.Medicare patients must be billed as.provider based how you charge and bill.your commercial or private payers.depends on your contract as long as you.don't.as long as you don't you know treat.patients differently would be my answer.okay then we can do one more.does the EMTALA rules apply to on-campus.provider based rh c yes okay thank you.again Linda for the great presentation.today good if you have questions please.just send them to my email I will be.glad to do my very best to help anyone.that has questions thank you all I.enjoyed it thank you so much and at this.time I would like to thank everybody for.joining us today I hope you can all join.us for our webinar at February webinar.as well and I remember have you exit.today's webinar you will be.automatically routed to a survey and I.mean your love for your feedback and.directions for future topics so thank.you again Linda for taking the time to.prepare and share your knowledge and.insight with our audience today and I.hope everyone had a great afternoon.you are welcome thank you all for.joining thank you bye.

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Cgs Provider Based Billing Attestation Statement Form FAQs

Here are some frequently asked questions along with their answers to clear up the doubts that you might have.

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If you work for yourself doing government contracts and American Express asks for you to show them a current pay stub, how would you provide that? Is there a form that has an earnings statement that you can fill out yourself?

All they really want is proof that someone is paying you money. If you are doing contract work for the government, at some point the government must have cut you a check. Show them that, and tell them how much of your work time it represents.

How can I fill out the form of DTE MPonline to take admission in IET DAVV Indore? Provide the site (link).

See their is no seperate form for iet davv, you have to fill this college during the choice filling stage of counselling. The procedure for the DTE counselling is very simple thier are 3 main steps you need to follow. Registration Choice filling Reporting to alloted institute. For all this the website you should visit is https://dte.mponline.gov.in/portal/services/onlinecounselling/counshomepage/home.aspx Here at the top right corner you will see a menu as select course for counselling, click on it, select bachelor of engineering then full time and then apply online. This is how you will register fo Continue Reading

How does one run for president in the united states, is there some kind of form to fill out or can you just have a huge fan base who would vote for you?

If you do not know the answer to this question, then I do not want you to run for President of the United States. I know the bar has been lowered mightily of late, but not enough.

Startup I am no longer working with is requesting that I fill out a 2014 w9 form. Is this standard, could someone please provide any insight as to why a startup may be doing this and how would I go about handling it?

Payment for surrender of your shares and possibly the cost of your "off the books" benefits is probably going to show up on a 1099. If you were an employee, this should actually be included on your W2 for the year in which they are paid. If you were not an employee, but an independent contractor, then you'll owe both the employer and employee's share of social security tax, medicare and income taxes.

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Many US employers today won’t allow individuals (coworkers, supervisors) at a company respond to any questions or write recommendations. Everything must go through HR and they will often only confirm dates of employment. I know this, so I’m not going to waste time contacting phone numbers/email lists of supposed former coworkers or managers. Fact is, if anyone answered and started responding to my questions, I’d be very suspicious. Instead, I just ask for the main number of the company — which I can look up on line and verify to be the actual number of the claimed company. Same deal with academi Continue Reading

What does Provider signature mean?

The gate agents probably write their initials on your boarding pass if your identification is ok. If your identification is not ok, they probably write “shoot this one”. Why do you feel the need to know, or publicize, confidential security procedures which are enacted for public protection? Really.

What is a signature attestation statement?

Without more info , it would be difficult to give a proper answer. But at the outset , yes it is. If there is a financial implication, only if the statement is on a govt bond paper it is valid and the document has to be attested by witnesses.

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