Duane C. Abbey

Provider-Based Rule – Update for 2019

Presenter : Duane C. Abbey, PhD
Duration : 90 Minutes



Product 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 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.

Session Objectives:

  1. To briefly review the Provider-Based Rule (PBR).
  2. To review the criteria that must be achieved for clinics to be recognized as provider-based.
  3. To update the current status of changes in payment to off-campus provider-based clinics as provided through Section 603 of the BBA 2015.
  4. To review the further changes made by the 21st Century Cures Act.
  5. To briefly update critical physician supervisory rule changes.
  6. To discuss documentation requirements relative to physician supervision requirements.
  7. To appreciate the increase in reimbursement for provider-based clinics.
  8. To understand the attestation and request for determination processes.
  9. To understand the need for updating and the documentation of organizational structuring relative to the PBR.
  10. To understand the review/audit process for assessing current and/or potential provider-based situations.
  11. To understand the economic benefits versus the compliance requirements.
  12. To appreciate the relationship of PBR relative to the Conditions for Payment, Conditions of Participation and gaining billing privileges.
  13. To understand the regulatory pressures for reducing reimbursement for provider-based clinics.
  14. To appreciate the evolving guidance that is being provided by CMS and/or the Regional Offices.
  15. To work through several case studies.

Session Agenda:

  1. Review of the Provider-Based Rule (PBR)
    1. Development of the PBR
    2. 42 CFR 413.65
    3. Review of Definitions
    4. Rules and Regulations
    5. Recognition by Non-Medicare Third-Party Payers
    6. Very Brief History of Provider-Based Clinics
  2. Economic Advantages of Provider-Based Status
    1. Clinics
    2. Clinical Services
    3. Costs for Provider-Based Status
  3. Current Activity Surrounding Medicare Payment for Provider-Based Clinics
    1. OIG Recommendations
    2. MedPAC Recommendations
    3. CMS Data Gathering of Cost for Off-Campus Provider-Based Clinics/Operations
      1. PO Modifier – UB-04
      2. POS 19/22 Indicators – 1500CY2018 & CY2019 OPPS Federal Register – Policy Change
    4. Section 603, BBA 2015 Changes Starting January 1, 2017
      1. Final Rules for 2017
      2. Payment Process or Non-Excepted Clinics
    5. Section 16001, 21st Century Cures Act
      1. Definition of ‘New’ Relative to BBA 2015
      2. Mid-Build Exception for Grandfathering
    6. CY2018 & CY2019 OPPS Federal Register – Policy Changes
    7. CY2018 & CY2019 MPFS Federal Register – Payment Processes
  4. Provider-Based Requirements – Special Issues
    1. Signage and Recognition
    2. EMTALA Interface
    3. Notice of Two Copayments
    4. Split-Billing
    5. Shared Space Concerns
    6. Co-Location Issues
    7. Under Arrangements
    8. Other Regional Office Issues
  5. Physician Supervisory Requirements
    1. Recent Changes and Clarifications
    2. Relationship to Physician Incident-To Billing
  6. Provider-Based Audits
    1. Process
    2. Data Gathering and Assessment
    3. Attestations and Requests for Determination
    4. Action Steps
  7. Provider-Based Clinics – The Future
  8. Case Studies – Provider Based Clinics
Related Courses:

Suggested Attendees:

  • Clinic Managers
  • Clinic Administrators
  • Coding Personnel
  • Billing and Claims Transaction Personnel
  • Nursing Staff
  • Clinical Service Area Personnel
  • Chargemaster Coordinators
  • Financial Analysts
  • Compliance Personnel
  • Physicians
  • Non-Physician Practitioners
  • Healthcare Auditors
  • Other Interested Personnel

About the Presenter:

Duane C. Abbey, PhD, CFP, is a management consultant and president of Abbey & Abbey Consultants, Inc., a consulting firm specializing in healthcare and related areas. Duane earned his graduate degrees at the University of Notre Dame and Iowa State University and has more than 20 years of experience as a consultant. Dr. Abbey works extensively in all areas relating to compliance reviews, coding, billing and reimbursement with particular emphasis on the chargemaster and outpatient payment. His consulting activities include hospitals and physicians based clinics.

In addition to his consulting practice, Dr. Abbey also teaches workshops and makes presentations on a regular basis. He has taught at the University level and speaks nationally. He is a regular presenter for hospital associations, medical societies, Boards of Trustees and various other organizations and groups. In addition, professional societies such as HFMA use Dr. Abbey’s services to present seminars and workshops.

Dr. Abbey is a nationally recognized expert in payment systems. A special area of expertise includes APGs/APCs. He is recognized as the leading expert in the nation in APGs/APCs by the thousands who have attended his seminars, read his publications and/or contracted for his services. Attendees at these seminars over the years have included personnel from hospitals, clinics, integrated delivery systems and multiple consulting firms.

Dr. Abbey is also the author of numerous articles and books including: Compliance for Coding, Billing & Reimbursement, Outpatient Services: Designing, Organizing & Managing Outpatient Resources, ChargeMaster: Review Strategies for Improved Billing and Reimbursement, Ambulatory Patient Group Operations Manual, published by McGraw-Hill and Non-Physician Providers: Guide to Coding, Billing & Reimbursement, Chargemasters: Strategies to Ensure Accurate Reimbursement and Compliance, and Emergency Department Coding & Billing: A Guide to Reimbursement & Compliance published.

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