As a rural health consultant myself with over twenty years in this profession and twelve years as a Fiscal Intermediary (MAC), I have seen what bad advice can do to a rural health clinic. Many times, I’ve been called in to pick up the pieces and help the practice get back on its feet. Let me give you some examples of the types of mistakes I have encountered and how an experienced rural health consultant would mitigate them.
Example 1
A Rural Health Clinic in central Florida had a contentious recertification by the State Agency. The surveyor was giving the business office manager a difficult time over their CLIA status and lack of Patient Care Policies. The physician intervened and the surveyor and physician got into a heated debate. The surveyor said that based on his findings, the clinic was out of compliance and he was going to recommend termination. The clinic called me and I spoke to the surveyor. He cited the discrepancies and I asked how he could recommend termination without giving the clinic the opportunity to take corrective action? When the surveyor returned 30 days later, the CLIA certificate still had not been issued and in spite of documentation that the business manager had, it was regarded as defiance. Additionally, the surveyor would not accept the adoption of the Nurse Practitioner Protocols as the clinic’s patient care policy. The surveyor again was going to recommend termination. I contacted the State Agency regional office and explained the situation but it fell on deaf ears. I contacted the CMS Ombudsman in Atlanta and furnished her with all the documentation showing that the surveyor and Regional Office were not following the State Survey Guidelines, but were, in fact, disregarding them. I assured her that the clinic was in compliance and had just received the CLIA approval. The clinic then received a visit from another surveyor and he was completely satisfied and the clinic was recertified.
Example 2
A Rural Health Clinic in west central Florida had a desk review of the prior year’s cost report and it was determined that a field audit would be warranted due to the lack of response for documentation. Apparently the office staff did not get the requests for additional information in a timely fashion. The physician contacted me and asked if I could assist the practice during the on-site field audit. A review of the case revealed that the MAC determined that the physician was well over the MD salary limits according to the MAC. The MAC used a Federal salary study by region for the basis of their determination of the reasonableness of the salary. The field audit lasted for four days and the exit conference indicated that there would be a substantial adjustment of more the half of the physician’s salary and fringe benefits. The adjustment would result in the cost-per-visit rate being sharply reduced which would impact the current year. I asked the auditor for the study which was used as the basis for the adverse determination and noticed that the study was more than 5 years old. The study was further flawed in it did not take into consideration the specialty, (this MD was an Internist) with advanced training (Board certification) and length of practice experience. I was able to secure a more current version of the study which had been updated and found that the physician was very close to the salary range when the other qualifications were taken into consideration. The result was that the adjustment was only 10% of the original determination and had no material effect on the clinic’s rate.
Example 3
A Rural Health Clinic in middle Alabama had a desk review of their prior year cost report bad debts. The MAC requested a statistically valid sample of bad debts that were in need of the EOMB (Explanation of Medicare Benefits) to justify the balances that were written off. Some of the bad debts were more than several years old and the documentation had been shredded by the clinic’s billing service. The MAC decided that without the EOMB the bad debts would be disallowed. The clinic was ordered to pay back a substantial amount resulting from the disallowances. Since the statistical sample was randomly selected, it was considered to be representative of the entire population. Unfortunately, the cases that had no EOMB were the very old ones which made up a small percentage of the entire bad debts but all were to be denied which skewed the sample. I argued that the sample was skewed and the percentage to be applied to the whole was not valid. The MAC did not agree and suggested that an appeal should be filed. The clinic would have to file a formal appeal through the PRRB. This could take up to several years and I knew this was not true so I suggested that the clinic contact Sen. Jeff Sessions, a friend of the clinic’s medical director and bring him into the case. Within three weeks the clinic was contacted by the MAC and told that most of the EOMBs had been found. The clinic was refunded most of their payback.
As you can see, hiring a rural health consultant with limited or no experienced can be just as risky as not hiring a consultant at all. In today’s market, most rural health clinics deeply depend on receiving the maximum Medicare reimbursement rate possible. One mistake by an inexperienced rural health consultant may result in an audit, and one failed audit could bring a clinic to its knees in short order. So what should you look for when hiring a rural health consultant? There are some obvious and not so obvious qualifications to consider.
First, the rural health consultant must have a detailed knowledge of all aspects of the Medicare Rural Health Program (Public Law 95-210). Technical, as well as practical knowledge of the conditions of participation, application submission, coverage issues, billing issues and most important Medicare cost reimbursement are critical to a Rural Health Consultant.
Second, an experienced rural health consultant should have a detailed knowledge of cost reporting and the factors which prompt red flags and potential desk audits. Additionally, if an audit is scheduled by the MAC, the rural health consultant should be available to the clinic to provide advice and technical assistance on a priority basis either by phone or on site.
Third, the rural health consultant must be able to engage not only the MAC staff and the State Agency staff on matters of findings and correct them when they are wrong or expressing their personal preferences even though those preferences may not be permitted in the regulations or operating instruction. The rural health consultant must be prepared to go to the CMS Regional or Home Offices to get a resolution to the problem. The rural health consultant must have contacts in higher places to present credibility of his knowledge and expertise in the areas of the issues.
By no means is this the entire list, but hopefully it will get you off to a good start. There are a number of rural health consultants in the market who have practice management experience, but zero experience when it comes to the Rural Health program. If you are having difficulty finding a tried, tested, and experienced consultant, contact me at (800) 592 – 3051.