Rural Health Clinic (RHC) Physician Eligibility for Medicare Incentives Discrepancy

Rural Health Clinic (RHC) Physician Eligibility for Medicare Incentives Discrepancy

There has been significant confusion as to which incentive programs Eligible Professionals (EPs) that practice in Rural Health Clinics (RHCs) qualify for. We know they qualify for the Medicaid incentives if they have a 30% “needy” patient volume threshold. The ambiguity has always been whether EPs that practice predominantly in RHCs and have less than the 30% “needy” patient threshold can then qualify for the Medicare incentives.

Why I believe EPs that practice predominantly in RHCs do not qualify for the Medicare Incentive:

In ARRA, covered professional services are defined as “the meaning given such term in (k) (3).” For those of us who do not speak in CMS, this phrase refers to section 1848 (k) (3) of the Social Security Act, which established RBRVS (Resource-Based Relative Value Scale) under which physicians bill Medicare for reimbursement using 1500 forms. The implication of this is that those physicians that do not bill with 1500s (such as physicians that practice in RHCs, which use UBs) do not provide eligible covered professional services and are therefore excluded from the ARRA Medicare incentive.

I think excluding RHC physicians was bad policy making, but the exclusion is in the statute.

The final CMS HIT Incentive Rule supports this interpretation with the following language (from Page 131):

Comment: A commenter suggested that the definition of allowable charges be amended to include the RHC schedule of services, or allow providers who use UB92 and HCFA 1500 forms to be eligible for the EHR incentive payment.

Response: The allowed charge is the amount that Medicare determines to be reasonable payment for a provider or service under Part B, including coinsurance and deductibles. RHC services furnished by an EP are not considered covered professional services for purposes of the Medicare EHR because they are not billed or paid under the physician fee schedule.

What is the Discrepancy?

However, CMS has posted an eligibility flowchart that contradicts this interpretation. According to the flowchart (which is available at http://www.cms.gov/MLNProducts/downloads/eligibility_flow_chart.pdf), an EP practicing predominantly in an RHC would answer the following questions to reach a different conclusion than the one I’ve articulated above. (FYI this form was pulled from the CMS website since I posted this blog, and now has been replaced with a new accurate flow chart at: http://www.cms.gov/EHRIncentivePrograms/Downloads/Eligibility%20Flow%20Chart_91510.pdf)

1. Did you perform 90% of your services in an inpatient hospital or emergency room setting? An EP practicing predominantly in an RHC would answer no.

2. Were at least 30% of your services furnished to Medicaid patients in an outpatient setting (20% for pediatricians)? An EP (practicing in an RHC) that answers yes would qualify for the Medicaid incentive program. An EP (practicing in an RHC) without 30% utilization would answer no and go to the next question.

3. Did you practice predominantly in an FQHC or an RHC with a 30% needy individual patient threshold? An EP (practicing in an RHC) that answers yes would qualify for the Medicaid incentive program. An EP (practicing in an RHC) without 30% “needy” utilization would answer no and go to the next question.

4. Do you treat Medicare patients? An EP (practicing in an RHC) would answer yes to this question. Assuming he or she would also answer yes to the question “are you a doctor?” they would be led to the Medicare incentive box.

For this flow chart to be consistent with the final rule, the question that needs to be stated is not whether the EP “treats Medicare patients” (which EPs in RHCs clearly do) but whether they “bill Medicare under RBRVS” (which they don’t).

The preliminary information I’ve received from a CMS contact is that the final rule is correct and the flowchart is “misleading.”

For anyone that doesn’t understand the stakes of this misrepresentation, I’m concerned that EPs that practice in RHCs will use the CMS flowchart, develop a misunderstanding, and then sign contracts with EMR vendors based on the assumption that they will be receiving Medicare incentives. I would encourage CMS to revise their flowchart and develop an FAQ clarification on this issue as soon as possible.