Provider-Based Rule – Update for 2019 by Duane C. Abbey

Description:-

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 the movement to change the rules and regulations relative to reimbursement for provider-based clinics. In this workshop, 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. 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 CY2018 and CY2019 OPPS and MPFS update Federal Registers will be discussed.

Teleconference/Webinar 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 provided through 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 economic benefits versus the compliance requirements.
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.
To work through several case studies.

Teleconference/Webinar Outline/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
Clinics
Clinical Services
Costs for Provider-Based Status
Current Activity Surrounding Medicare Payment for Provider-Based Clinics
OIG Recommendations
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 Changes Starting January 1, 2017
Final Rules for 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
CY2018 & CY2019 OPPS Federal Register – Policy Changes
CY2018 & CY2019 MPFS Federal Register – Payment Processes
Provider-Based Requirements – Special Issues
Signage and Recognition
EMTALA Interface
Notice of Two Copayments
Split-Billing
Shared Space Concerns
Co-Location Issues
Under Arrangements
Other Regional Office Issues
Physician Supervisory Requirements
Recent Changes and Clarifications
Relationship to Physician Incident-To Billing
Provider-Based Audits
Process
Data Gathering and Assessment
Attestations and Requests for Determination
Action Steps
Provider-Based Clinics – The FutureCase Studies – Provider-Based Clinics

Prerequisites for Participating:- 

General knowledge of hospitals and various clinic and/or clinical operations.

Suggested Attendees:- 

All personnel involved with the provider-based clinic and/or clinical operations, compliance personnel, coding and billing personnel, nursing staff and interested physicians are encouraged to attend.