What special coding and billing requirements are required for provider-based clinics? What are the requirements under the provider-based rule (PBR)? What do hospitals have to do to establish provider-based clinics? To answer these questions and more please come join us in this upcoming Webinar.

Webinar Objectives

• Review the Provider-Based Rule (PBR)

• Understand the differences between freestanding and provider-based clinics

• Understand the economic advantages of provider-based clinics

• Appreciate special requirements for provider-based clinics

• Appreciate special compliance concerns associated with provider-based status

• Understand the steps needed to create and/or convert to a provider-based clinic

• Discuss coding and billing issues for provider-based clinics

• Delineate how the chargemaster should be established to support coding and billing for both technical and professional components

• Discuss operation issues such as setting fees, patient relations and medical staff organizational structuring

• Work through several case studies involving the establishment of the provider-based clinics 

The following are a few of the topics to be discussed

• 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

• Economic Advantages of Provider-Based Status

  • Clinics

  • Clinical Services

  • Costs for Provider-Based Status

  • Recognizing Provider-Based Clinical Services

• Establishing Provider-Based Clinics

  • Meeting the PBR Requirements

  • Special Areas of Concern

    • Medical Records Integration

    • Off-Campus vs. On-Campus

    • Physicians and Practitioners

    • EMTALA Compliance

    • Fire Safety Concerns

    • Hospital Conditions of Participation

    • Human Resource Issues

  • Physician Supervision Requirements

• Coding and Billing

  • Technical Component E/M Coding

  • Surgical Services Coding

  • Medical Services Coding

  • Setting Up The Chargemaster

    • Establishing Charge Structures

    • Use of Modifiers

• Special Types of Provider-Based Clinics

  • Wound Care Clinics

  • Specialty Clinics

  • Pain Management Clinics

  • Medication Management Clinics

• Sources for Further Information 

Target Audience

Chargemaster personnel, compliance personnel, claims transaction personnel, financial analysts, operating officers, clinic administrators and managers, and all personnel involved with provider-based clinics and/or clinical operations including nursing staff and interested physicians/practitioners.

Review the Provider-Based Rule and Make Smarter Choices for Your Hospital and Clinic

Understanding the Provider-Based Rule (PBR) can be a tall order, especially as changes in the physician supervision and reimbursement rules add confusion. Not only do hospitals’ provider-based operations face unique billing and operations issues, but PBR ambiguities—from multiple PBR-status criteria to joint-use/time-share spaces to signage requirements—make compliance a real challenge. Learn to weigh the economic benefits and compliance concerns of provider-based operations—and make smarter choices for your hospital and clinic.

Join expert speaker Duane C. Abbey, Ph.D, as he explains the key differences between freestanding and provider-based clinics, and the economic advantages of the latter. He will teach you to set fees for your clinic, conduct patient relations, and effectively organize your medical staff. Abbey will walk you through all the complex PBR compliance details, including how to: apply the physician supervision requirements for outpatient services , abide by reporting requirements, use CMS-855 enrollment forms, qualify clinics that are outside the 35-mile default limit, and audit your clinic operations.

The 2017 Outpatient Prospective Payment System (OPPS) rule changed how non-exempted off-campus provider-based departments will be paid. And both Section 603 of the 2015 Bipartisan Budget Act (BiBA) and Section 16001 of the 21st Century Cures Act have significantly affected the establishment and payment systems of provider-based clinics. Be sure your clinic is up-to-date and being paid appropriately!

After attending this informative session, you will be well equipped to implement all PBR-specific billing and coding requirements—and be audit-ready at all times. By the end of this information-packed session, you will have the tools you need to understand how federal legislation and billing requirements converge to impact how your clinic will be paid.

Session Highlights

This program will teach you how to:

• Qualify clinics outside the 35-mile default limit
• Apply provider-based reporting requirements and fill out the CMS-855 forms
• Clarify which criteria must be met in order to qualify for provider-based status
• Improve operations, such as setting fees and structuring staff
• Gauge how PBR ambiguities may be affecting your operations and how to gain clarity
• Get started on upgrading your  provider-based clinic’s coding and billing practices
• Determine how and when to audit your provider-based operations to remain compliant with CMS

Session Objectives:  

In this session you will be able to:

• Briefly review the Provider-Based Rule
• Understand the differences between freestanding and provider-based clinics
• Understand the economic advantages of provider-based clinics
• Review and appreciate special requirements for provider-based clinics
• Appreciate special compliance concerns associated with provider-based status
• Discuss coding and billing issues for provider-based clinics
• Understand how to qualify clinics that are outside the 35-mile default limit
• Discuss signage and proper identification for provider-based operations
• Explore complicated issues such as joint use of space and time-share space utilization
• Understand provider-based reporting requirements and the CMS-855 forms
• Explore the application of the physician supervision requirement for outpatient services
• Discuss operation issues such as setting fees, patient relations and medical staff organizational structuring
• Review on-going ambiguities in the Provider-Based Rule affecting provider-based operations
• Analyze the impact of 603 BiBA 2015 and Section 16001 of the 21st Century Cures Act affected establishing provider-based clinics?
• To work through several case studies involving special issues in the establishment of the provider-based clinics

Session Agenda:

• Review of the Provider-Based Rule
  • Development of the PBR
  • 42 CFR §413.65
  • Review of definitions
• Economic advantages of provider-based status
  • Clinics
  • Clinical services
  • Costs for provider-based status
  • Recognizing provider-based clinical services
• Establishing provider-based clinics
  • • Meeting the PBR requirements
    • Coding and billing for provider-based clinics
    • Physician supervision requirements
    • CMS 855 forms
      • CMS-855-B
      • CMS-855-A
      • CMS-855-I
• Recent legislation
  • Section 603 of BiBA 2015
  • Section 16001 of the 21st Century Cures Act
• Special issues and sensitivities
  • Split-billing
    • 1500 claim form requirements
    • UB-04 claim form requirements
  • ‘Holding-Out to the Public” – proper signage
  • Split-use facilities
  • Time-share use of facilities
  • Cost reporting issues
  • Qualifying clinics that are outside the 35-mile default
  • Requesting determinations and filing attestations
  • 3-day payment window issues – freestanding vs. provider-based
  • Affiliated hospitals and remote campuses
  • Related laboratory and radiology issues
• Case studies
• Sources for further information

Who Should Attend

All persons involved with provider-based clinics will benefit from this session, including:

• Claims transaction and compliance personnel
• Financial analysts
• Operating officers
• Clinic administrators and managers
• Coding personnel
• Chargemaster personnel
• Nursing staff
• Physicians/practitioners

The chargemaster is both a direct and indirect target of compliance and thus various types of audits.  Hospitals should periodically take the time to examine their chargemasters from a compliance perspective.  This means examining and review various CDM policies and procedures (P&Ps) which must dovetail to coding P&Ps as well as billing P&Ps.  Issues such as transparent pricing, proper use of revenue codes, cost report interface, coding interface, billing interface, supply categorization, etc. must all be considered.  A systematic process for auditing the chargemaster relative to this host of compliance issues is discussed.

• Why is the chargemaster a direct target for compliance?
• Are formal, chargemaster policies and procedures important?
• Should the chargemaster be routinely reviewed as a good compliance practice?
• What is all the concern about archiving the chargemaster?
• Are statutory and contractual requirement for the chargemaster significantly different?
• Why has chargemaster pricing become such a hot compliance issue?
• How can we know that our chargemaster is in compliance?
• Are the revenue codes really important?

 Objectives:- 

1. To review the purpose, function and organization of the chargemaster.
2. To appreciate that the chargemaster is both a direct and indirect concern for compliance.
3. To appreciate the difference between statutory and contractual compliance issues.
4. To discuss the attributes that are necessary to maintain chargemaster compliance including revenue codes, CPT/HCPCS codes and pricing.
5. To appreciate the compliance areas that may be reviewed by external auditors and governmental entities including the RACs.
6. To appreciate the indirect impact that the chargemaster has on other compliance concerns including coding, billing and payment.
7. To understand the differences between separately charging and separately billing or separately reporting.
8. To appreciate the proper use of revenue codes and the potential impact on the cost report.
9. To discuss the development of CDM P&Ps which must properly correlate to coding P&Ps and billing P&Ps.
10. To review various compliance issues related to the CDM and the policy decisions that must be made in order to maintain compliance.
11. To appreciate different levels and forms of guidance from CMS, which sometimes conflict.

Webinar Agenda:- 

1. Overview of the Chargemaster
   1. Role, Purpose, Function and Organization
   2. Chargemaster Interfaces
   3. Direct versus Indirect Compliance Concerns
2. Types and Levels of Compliance Concerns
   1. Statutory Requirements
      1. Medicare
      2. Other Governmental Programs
   2. Contractual Obligations
      1. In the Contracts
      2. References to Companion Manuals
3. Chargemaster Compliance
   1. Internal Code Sets
   2. Correlation of Line Items
   3. Proper Assignment of Revenue Codes
   4. Proper Pricing and Charge Structures
   5. Developing Proper Cost-to-Charge Ratios (CCRs)
4. Indirect Areas of Chargemaster Compliance
   1. Cost Report
   2. Cost Accounting
   3. Correct Coding
   4. Proper Claim Generation
5. Governmental Auditing Programs
   1. Levels and Types of Rules and Regulations
   2. Ambiguous and Conflicting Guidance
   3. DOJ and CMS
   4. RACs
6. Sources for Further Information

Who Will Benefit:

Chargemaster Personnel, Coding Personnel, Billing and Claims Transaction Personnel, Chargemaster Coordinators, Cost Report Preparers, Compliance Officers and Compliance Personnel, Auditing Personnel, Revenue Cycle Personnel, Clinical Service Providers, Financial Analysts, Compliance Personnel, Physicians and Other Interested Personnel

Preventing unnecessary readmissions is essential. Hospitals that have a higher rate of readmission now receive less money from CMS. This is why there is increased surveillance activity in the area of discharge planning.

This program will cover the CMS (Center for Medicare and Medicaid Services) hospital Conditions of Participation regulations for Utilization Review. Every hospital that accepts Medicare and Medicaid reimbursement must be compliance with these standards. Compliance with the UR standards is more important to avoid penalties from the Recovery Audit Contractors (RACs) and other organizations such as the OIG.

After this webinar participants will be able to:

1. Recall that the hospital must have a UR plan.
2. Discuss the importance of documentation of medical necessity by the physician in the medical record.
3. Describe that hospitals are required to have a UR Committee.
4. Recall there are three revised tag numbers.

Agenda topics:

Target Audience:

Anyone involved with or interested in utilization review, including but not limited to: Utilization Review Committee, Transitional Nurses, UR Nurses, CEOs, CFOs, COOs, CMOs, CNOs, CE Directors, Department Directors, Quality Improvement Staff, Physicians, Nurses (all levels), Compliance Officers, CMS Liaisons, TJC Liaisons, Safety Officers and Staff, Ethics Committee Members, Consumer Advocates, Risk Managers, Social Workers, Discharge Planners, Case Managers, Hospice Staff and Regulatory Affairs Staff.

The QAPI (Quality Assessment and Performance Improvement) worksheet is designed to help surveyors assess compliance with the hospital CoPs for QAPI. The worksheet is used by State and Federal surveyors on all survey activity in hospitals when assessing compliance with the QAPI standards including validation and certification surveys. CMS may also just show up at your door to assess the three worksheets.

This program is a must attend for any hospital. This is because it is one of only three sections with a CMS worksheet. It will also discuss the CMS hospital QAPI standards. There is high number of deficiencies and these will be discussed. There are over 1,700 deficiencies and many of these relate to patient safety. This program will also cover some proposed changes to QAPI. CMS is going to implement similar QAPI standards for critical access hospitals in the proposed Hospital Improvement Rule.

After this webinar participants will be able to:

1. Recall that CMS has a worksheet on QAPI.
2. Describe that there is a section on QAPI in the CMS hospital CoP manual that any hospital that accepts Medicare or Medicaid reimbursement must follow.
3. Discuss that the Board is ultimately responsible for the QAPI program and must ensure there are adequate resources for PI.
4. Recall that hospitals are receiving a high number of deficiencies in QAPI.

Agenda topics:

Target Audience:

It should be mandatory for the performance improvement director and staff to attend. Others include the risk management, quality staff, compliance officer, chief nursing officer, chief medical officer, patient safety officer, nurse educator, staff nurses, nurse managers, leadership staff, board members, accreditation staff, department directors, infection preventionist and anyone else who is responsible to ensure the CMS CoPs related to performance improvement are met which includes requirements on risk management and patient safety.

In this session Mr. Wolfe will provide a straight-forward, practical explanation of developing concepts, including the quality and value metrics into new federal health care programs and commercial payment systems.

New delivery models, what providers can be doing to develop a value-based strategy, and the application of the Stark Law and other fraud and abuse laws to new models aimed at population health, quality of care and cost control. 
Mastering these concepts will be a must for health care executives looking to position their organizations for success in this new value-based world.   

Why should you Attend: 

Going forward, health care leaders should be developing a value-based strategy so they can position their organizations for financial success in the new value-based world.
A refined and comprehensive value-based strategy can advance several important goals for a health care organization, among them:

(1) enhancement of quality of care and improvement of patient outcomes.

(2) promotion of safe medical practices.

(3) sharing of best clinical practices.

(4) increased efficiencies in care delivery.

(5) facilitation of appropriate utilization of services; and

(6) alignment of financial incentives.

Attendees should register for this webinar to get a better understanding of the legal issues surrounding paying for quality and value so they can refine their current strategy and can identify new delivery models and potential opportunities. 

Areas Covered in the Session:

• Provide a general overview of new quality and value-based payment trends
• Discuss potential strategies for incentivizing physicians in connection with the rollout of the new value-based programs
• Discuss the application of the existing regulatory framework (e.g, AKS, Stark, CMP, beneficiary inducement, etc.) to new models aimed at incentivizing population health, quality of care and cost control

Who Will Benefit:

• In-House Counsel
• Health Care Compliance Officers
• Health Care Human Resources
• Health Care CFOs
• Health Care Executives

HIPAA enforcement activity is well established now, with new attention to reported violations of HIPAA.  It is easy to become the target of a compliance investigation, and essential to be prepared in advance.

HIPAA Compliance requires that you be prepared to handle Protected Health Information properly and follow the requirements in the HIPAA Privacy, Security, and Breach Notification Rules.  If there is a problem that comes to the surface, an enforcement action can result, including financial settlements that can reach into the millions of dollars, and Corrective Action Plans that can take years to complete and can cost many times the expense of the monetary settlements. 

We will review the contents of the updated 2018 HIPAA Audit Protocol to show what documentation needs to be on hand should your organization be selected for a compliance review.  We will present methods for using the contents of the HIPAA Audit Protocol to build your own compliance plan by relating your compliance activities directly to the questions that might be asked.

In this session we will discuss the HIPAA enforcement regulations and processes, how they apply to HIPAA covered entities and business associates, and how state Attorneys General can use the provisions enacted in the HITECH Act to file suit under Federal law.  We will explain the enforcement regulations and the increased fines and new penalty levels, including penalties for willful neglect of compliance that begin at $10,000 and reach into the millions of dollars.

Areas Covered in the Session:-

Learn about how the HIPAA enforcement rules work, and how HIPAA investigations can take place.

• Find out how state Attorneys General can initiate enforcement actions through filing civil suits under Federal Law.
• Learn about the penalties that can apply for non-compliance with accepted health information privacy and security practices.
• Find out what you'll need to have documented to survive an audit or compliance review and avoid fines.
• Learn how to make the HHS HIPAA Audit Protocol useful to you as a way to organize and track your compliance work, and collect your documentation references.
• Learn how to use an information security management process to evaluate risks and make decisions about how best to protect health information and meet patient needs and desires, as well as avoid penalties for non-compliance.

Why Should You Attend:-

In this session we will discuss HIPAA enforcement activities and how they work, including how state Attorneys General can play a role in enforcement, and discuss the areas that caused the most issues in prior audits and enforcement actions.  We will explore what kind of issues and what kind of entities had the most problems, and show where entities need to improve their compliance the most.  We will also explore the typical risk issues that lead to breaches of health information and see how those issues may lead to significant penalties for non-compliance.

We will discuss what information and documentation must be prepared in advance so that you can be ready for an audit or enforcement review at any time, including sample information request forms and questions asked in prior audits and reviews.  The session will also cover how to know if you may become the subject of an audit or enforcement action, and what you can do to help limit your exposure.  We will discuss how most enforcement actions come about and what can be done to prevent incidents that lead to enforcement activity.

The results of prior HIPAA audits and enforcement actions (and their penalties) will be discussed, including recent actions involving multi-million-dollar fines and settlements, as well as penalties levied as a result of state lawsuits.  A plan for attaining compliance will be presented.  The steps to follow to prepare for and respond to a compliance review or audit request will be outlined.  

Background:-

Enforcement of the HIPAA Privacy and Security Rules has become a significant reality, and now not only is the US Department of Health and Human Services Office for Civil Rights involved, with penalties in the millions of dollars, but also individual state Attorneys General are also picking up the enforcement ball and running with it, leading to several recent penalties in the hundreds of thousands of dollars.  Even if there is a slowdown in enforcement at the Federal level, enforcement activities continue where the state AGs see their states’ residents’ rights to the privacy and security of their health information threatened.  Now, more than ever, it is essential to have your HIPAA compliance in order so you can avoid the significant penalties for non-compliance.

Who Will Benefit:-

Attendees should include Compliance Officers, Privacy and Security Officers, and leadership and staff in health information management, information security, and patient relations, as well as staff in patient intake and front-line patient relations and any others that are involved in, interested in, or responsible for, patient communications, information management, and privacy and security of Protected Health Information under HIPAA, including:

• Compliance director
• CEO
• CFO
• Privacy Officer
• Security Officer
• Information Systems Manager
• HIPAA Officer
• Chief Information Officer
• Health Information Manager
• Healthcare Counsel/lawyer
• Office Manager
• Contracts Manager

When new drugs or devices are tested in humans, the data generated by, and related to, these trials are known as clinical data. This data represents a huge investment by the biopharmaceutical or device company and is one of its greatest assets. It is this data that will eventually make a new product both useful as a treatment or therapy and marketable.

The management of clinical data, from its collection during a trial to its extraction for analysis, has become a critical element in the steps to prepare a regulatory submission and to obtain approval to market a treatment. As its importance has grown, clinical data management (CDM) has changed from an essentially clerical task in the late 1970s and early 1980s to the highly computerized specialty it is today.

This seminar is based on the current state of regulations and will cover the essential parts of the data management plan, study start up, study conduct, study closeout and study monitoring. 

A data management plan or DMP is a formal document that outlines how data are to be handled both during a research project, and after the project is completed. The goal of a data management plan is to consider the many aspects of data management, metadata generation, data preservation, and analysis before the project begins; this ensures that data are well-managed in the present, and prepared for preservation in the future.

Study start up activities include designing case report forms (CRFs), paper or computer; specifying cleaning rules (edit checks); building and testing the database; and releasing the study database to collect data. 

Study conduct activities include collecting the data on CRFs and via electronic files, cleaning that data, managing adverse event and serious adverse event collection, and producing reports. 

Study closeout focuses on ensuring the data is complete and of a quality to support final analysis. 

Study monitoring is an in-person evaluation carried out by sponsor personnel or representatives at the sites at which the clinical investigation is being conducted. On-site monitoring can identify data entry errors (e.g., discrepancies between source records and case report forms (CRFs)) and missing data in source records or CRFs; and assess compliance with the protocol and investigational product.

Agenda:-

Lecture 1:-

Study Conduct

• Data Entry
• External Data integration and reconciliation
• Discrepancies, errors, corrections
• Data Cleaning (preparation) and Coding

Lecture 2 :-

Study Conduct (cont'd)

• (MedDRA and WHODDE dictionaries)
• Severe adverse events (SAE) status reporting
• Data Review and Quality Control
• Data Transfer procedures

Lecture 3 :-

Study Closeout

• SAE Reconciliation
• Quality Control
• Database Lock
• Electronic Archival
• Database Transfer
• Enhancing Reproducibility

Lecture 4 :-

Monitoring Visits

• What to expect during a monitoring visit
• Elements for Establishing a Corrective Action Plan
• Jeopardy Quiz - Clinical Data Management

Why you should attend:-

At the end of this class (Part I & Part II) attendees will be able to:

• Define best practices as they apply to CDM processes
• Describe CDM processes from study start-up to database lock
• Apply best practice rationale when assessing data collection requirements/instruments
• Evaluate the benefits of standardization in establishing CDM processes
• Discuss current technology/methods of data collection and associated documentation

Who Will Benefit:-

• New or aspiring Clinical Data Managers
• Clinical Data Managers
• Data Coordinators
• Clinical Research Associates
• Data Management Personnel
• Biostatisticians
• Regulators
• Doctors
• Nurses
• Project Managers
• Government employees at clinicaltrials.gov
• College Students and New Graduates in a Scientific Field
• This course is also ideal for “on-boarding” of individual new hires or entire teams