As a rural well being consultant myself with over 20 years in this profession and twelve years being a Fiscal Intermediary (MAC PC), I have seen what bad advice are capable of doing to a rural well being clinic. Many times, I’ve been called in to grab the pieces and help the practice reunite on its feet. I want to give you some samples of the types of mistakes We have encountered and how a seasoned rural health consultant would certainly mitigate them.
A Rural Health Medical center in central Florida acquired a contentious recertification from the State Agency. The surveyor was giving the business enterprise office manager a challenging time over their CLIA status and not enough Patient Care Policies. Health related conditions intervened and the surveyor and physician experienced a heated debate. The surveyor said that according to his findings, the clinic was away from compliance and he would definitely recommend termination. The clinic called myself and I spoke for the surveyor. He cited the inacucuracy and I asked just how he could recommend firing without giving the clinic the ability to take corrective actions? When the surveyor returned 1 month later, the CLIA certificate still wasn’t issued and in spite of documentation the business manager had, it absolutely was regarded as defiance. In addition, the surveyor would not necessarily accept the adoption with the Nurse Practitioner Protocols because the clinic’s patient care coverage. The surveyor again would definitely recommend termination. I contacted hawaii Agency regional office and explained the specific situation but it fell about deaf ears. I contacted the CMS Ombudsman inside Atlanta and furnished her with all the current documentation showing that the particular surveyor and Regional Office are not following the State Questionnaire Guidelines, but were, in reality, disregarding them. I assured her the clinic was in complying and had just acquired the CLIA approval. The clinic then received a trip from another surveyor and also he was completely satisfied as well as the clinic was recertified.
A Rural Health Medical center in west central California had a desk report on the prior year’s cost report plus it was determined that any field audit would be warranted as a result of lack of response regarding documentation. Apparently the office staff failed to get the requests for additional information in a timely fashion. The physician contacted me and asked easily could assist the practice through the on-site field audit. Analysis the case revealed the MAC determined that health related conditions was well over the particular MD salary limits in line with the MAC. The MAC used any Federal salary study by region for your basis of their determination with the reasonableness of the wage. The field audit held up for four days as well as the exit conference indicated that there would have been a substantial adjustment of more the half the physician’s salary and also fringe benefits. The adjustment would bring about the cost-per-visit rate being sharply reduced which will impact the current yr. I asked the auditor for your study which was used because the basis for the adverse determination and pointed out that the study was greater than 5 years old. The study was further flawed inside did not take into account the specialty, (this MD has been an Internist) together with advanced training (Table certification) and amount of practice experience. I surely could secure a more current version with the study which had recently been updated and found the physician was very near the salary range when one other qualifications were considered. The result was the adjustment was only 10% with the original determination and had no material influence on the clinic’s rate.
A Rural Health Medical center in middle Alabama had a desk report on their prior year cost report debt. The MAC requested any statistically valid sample of debt that were needing the EOMB (Reason of Medicare Benefits) to be able to justify the balances that have been written off. Some with the bad debts were greater than several years old as well as the documentation had been shredded from the clinic’s billing service. The MAC decided that minus the EOMB the bad debts could be disallowed. The clinic was ordered to cover back a substantial amount resulting from the disallowances. Since the particular statistical sample was at random selected, it was regarded as being representative of the complete population. Unfortunately, the cases that acquired no EOMB were ab muscles old ones which made up a small % of the entire debt but all were being denied which skewed the particular sample. I argued the sample was skewed as well as the percentage to be placed on the whole was not necessarily valid. The MAC failed to agree and suggested an appeal should be registered. The clinic would must file a formal appeal from the PRRB. This could use up to several years and I knew this is not true so I suggested the clinic contact Sen. Rob Sessions, a friend with the clinic’s medical director and bring him in to the case. Within three weeks the particular clinic was contacted from the MAC and told that a lot of the EOMBs had been identified. The clinic was refunded nearly all of their payback.
As you can view, hiring a rural well being consultant with limited or no experienced may be just as risky since not hiring a consultant in any way. In today’s market, most rural health clinics deeply be determined by receiving the maximum Medicare health insurance reimbursement rate possible. One mistake by a great inexperienced rural health consultant may bring about an audit, and one failed examine could bring a medical center to its knees promptly. So what should you try to find when hiring a countryside health consultant? There are some obvious rather than so obvious qualifications to take into account.
First, the rural health consultant will need to have a detailed knowledge of most aspects of the Medicare health insurance Rural Health Program (Community Law 95-210). Complex, as well as practical familiarity with the conditions of engagement, application submission, coverage concerns, billing issues and most critical Medicare cost reimbursement are critical with a Rural Health Consultant.
Next, an experienced rural health consultant needs to have a detailed knowledge of cost reporting as well as the factors which prompt warning flag and potential desk audits. In addition, if an audit is scheduled from the MAC, the rural health consultant needs to be available to the clinic to offer advice and technical assistance over a priority basis either simply by phone or on web site.