Provider-Based Rule Update for 2020: Advanced Issues in Establishing Provider-Based Clinics

Establishing Advanced Provider-Based Clinics for 2020: Now and the Future

Hospitals are ever-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 a movement to change the rules and regulations relative to reimbursement for provider-based clinics.

Working through several Case studies in this workshop by expert presenter, Duane C. Abbey, CFP,  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.  Reimbursement for G9463 for both exempt and non-exempt clinics will be addressed. 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 CY2019 and CY2020 OPPS and MPFS update Federal Registers will be discussed.

Session 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 in 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 reduced reimbursement for G0463.
• 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/or the Regional Offices.

Session 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: 1- Clinics and Clinical Services;2- Costs for Provider-Based Status
• Current Activity Surrounding Medicare Payment for Provider-Based Clinics
  • OIG Recommendations and 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 Final Changes Starting January 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
  • CY2019 & CY2020 OPPS Federal Register – Policy Changes
  • CY2019 & CY2020 MPFS Federal Register – Payment Processes
• Provider-Based Requirements – Special Issues
  • Payment for G0463
  • Signage and Recognition
  • EMTALA Interface
  • Notice of Two Copayments; Split-Billing
  • Shared Space Concerns, Co-Location Issues
  • Under Arrangements, and Other Regional Office Issues
• Physician Supervisory Requirements: Recent Changes and Clarifications; Relationship to Physician Incident-To Billing
• Provider-Based Audits
  • Process, and Action Steps; Data Gathering and Assessment
  • Attestations and Requests for Determination
• Provider-Based Clinics – The Future; Case Studies

Who Should Attend:-

• Clinic Managers, and Clinic Administrators
• All personnel involved with the provider-based clinic and/or clinical operations
• Compliance personnel
• Coding and billing personnel
• Personnel related to operational issues for Provider-based clinics
• Nursing staff and interested physicians are encouraged to attend