Frequently Answered Questions

Here are the questions we get most often. If you have questions not listed here, please Contact Us and we will be glad to help you find the answers.

Question: I have recently lost my midlevel practitioner and am in the process of looking for a physician assistant or nurse practitioner to hire for my rural health clinic. Do I have to notify anyone that I no longer have a midlevel working in the RHC?

Answer: One of the requirements of being a certified rural health clinic is that an existing clinic must have a physician assistant, nurse practitioner, or certified nurse midwife available to see patients 50% of the time it is open to provide medical services. In the event the midlevel leaves employment of the RHC, a waiver can be requested from the state agency that surveyed the clinic.
      In Texas, the Department of Health's Facility and Compliance Division's Zone Administrators are the offices that will grant a waiver to operate without a midlevel being available. This applies only to RHCs that already have their RHC provider number. Clinics waiting to became certified RHCs are not eligible for this waiver.
      A participating RHC may request a waiver when it loses its physician assistant, nurse practitioner, or certified mid wife in the previous 90 day period. A waiver can be granted for a period up to a year. However the RHC can not make a request less than six months after the expiration of any previous such waiver for the facility. The RHC must submit written documentation to their Texas Department of Health Zone office demonstrating its reasonable efforts to hire the required staff.

Question: We are a rural community hospital and have a couple of hospital owned rural health clinics (provider based clinics). However due to some changes in our accounting policies and the fact that one clinic is located at some distance from the hospital which may not meet the criteria of provider based, we want to change their RHC status. What do we do to still own the clinics but change them over to independent (freestanding) status?

Answer: Just notify the state agency (zone office) in writing that the clinic(s) wants to change its status from Provider Based to Free Standing with any written documents, if they have any. The state should then prepare a Form 1539 to be sent to the Centers for Medicare and Medicaid Services (CMS). CMS will notify the fiscal intermediary.

Question: What can you tell me about federally qualified health centers? With funding being spent to expand these community health centers, we are thinking about converting to one.

Answer: I have had a number of phone calls and e-mails from RHCs asking questions about Federally Qualified Health Centers (FQHC). I believe the majority of these questions can be answered by looking at the Rural Assistance Center's (RAC) web page on the FQHC program. That link is www.raconline.org/info_guides/clinics/fqhcfaq.php

Question: I am interested in taking over an existing RHC and the current owner says he will sell the clinic building and medical equipment at the current market price. However, he says that if I want the clinic's RHC certification I will have to pay him for it. Is this right? He said he did all the work to get the certification and it is his number to do as he wants.

Answer: Questions like can be addressed to your zone administrator, which is what I did. For the name of your Texas Department of Health Compliance and Licensing Zone Administrator, go to the resource web page and click on the Facility Compliance and License Division and scroll through it to find the button to the Zone addresses.The answer I received to the question of selling a certified RHC's number is:

To quote from the Regional Survey and Certification (RS&C) letter 98-06, dated April 27, 1998:

" A Medicare provider number is just a means of identifying {providers and suppliers} which participate in the Medicare program. when there is a transfer of ownership for Medicare purposes, we anticipate that there is a transfer of ownership in a business entity and that the entity continues to provide services to the community......The purchasing entity is not buying a Medicare number, it is obtaining a {provider or supplier} which is in full operation and meets Medicare regulations. The Medicare number is an identification for Medicare purposes."

Section 3210 of the State Operations Manual (CMS Pub. 7) states:

"When a provider undergoes a CHOW {change of ownership}, the provider agreement {and number} is automatically assigned to the new owner unless the new owner rejects assignment of the provider agreement."

Thus, the old owner cannot sell and the new owner cannot buy the Medicare provider agreement and number – they already belong to the new owner unless the new owner rejects assignment in writing.
      A survey of a RHC that had undergone a CHOW does not usually require a survey.If the new owner rejected assignment of the Medicare provider agreement {and number}, then they would be required to apply just as a new RHC would, and an initial survey would be conducted.
       Anyone that tries to sell a Medicare provider agreement (or number) should be reported to the Inspector General (IG) of the U.S. Department of Health and Human Services (DHHS) for investigation of fraud.

Question: I have heard there are extra benefits to working in a rural shortage area of a HPSA or MUA. What are some of the advantages?

Answer: There are a number of advantages from helping get school loans paid off to increased Medicare payments in rural geographic HPSAs to having a clinic designated as a federally certified rural health clinic or federally certified community health center. If you want to know what these shortage designations offer to rural Texas, you can check on our resource page at the TDH Health Professions Resource Center link and look for the benefit and incentive programs related to HPSA, MUA & MUP. Or go to http://www.tdh.state.tx.us/dpa/benefits.pdf

Question: I have heard that physicians in Health Professional Shortage Area (HPSA) locations can get an increase in their Medicare payment by using a modifier to show they practice in a rural area, what is this program and can my RHC bill for this also? What is the modifier called?

Answer: The Medicare Bonus Payment program with a QU or QB modifier you are referring to is the fee-for-service Medicare services performed by a physician who provides healthcare in a designated Primary Care Geographic HPSA location. Its is a 10% bonus payment for the Medicare Part B physician-performed services, i.e. the physician professional component of medical services. It is not applicable for Medicare beneficiaries in a Medicare Advantage (Medicare+Choice) plan. It is also not a "paid incident to" situation but must be performed by the actual Medicare Part B participating physician. Lab physician interpretation and anesthesia are also included in this bonus payment. Neither the doctor nor the patient needs to reside in the shortage area, but services must be provided within the shortage area boundary.
       However, certified Rural Health Clinics are not eligible for this bonus payment since they are paid on the RHC all inclusive encounter rate.
       But that does not mean the physician is automatically excluded from this Part B bonus payment. If the physician is not providing RHC services, say for example it is his/her hospital in-patient care being billed to Part B, then that is eligible for the bonus payment provided the services are rendered in a designated HPSA location. There is also an extra 5% added to the 10% bonus if the Part B physician professional component services are performed in a designated Physician Scarcity Area (PSA). These additional five percent PSA payments are effective January 1, 2005 through December 31, 2006.
      The modifier usage is no longer needed because the Fiscal Intermediaries (FI) are now paying the bonus based on the location of services as indicated by the ZIP Code used on the CMS Billing Form 1500.

Links to the Medicare bonus payment program are:

General information
www.cms.gov/providers/bonuspayment/

Areas eligible for bonus payments:
www.trailblazerhealth.com/tools/hpsa/index.asp

CMS information article:
www.cms.hhs.gov/medlearn/matters/mmarticles/2005/SE0449.pdf

Question: I have a RHC Medicare patient who initially came to the clinic for a work related injury to his back, and while there the provider also treated the person for the flu he is suffering. Can I bill the worker's comp and also bill the Medicare fiscal intermediary? It is two separate things we treated the patient for and it seems that the money would come from two different sources.

Answer: The entire bill is sent to the worker's compensation organization and they pay for the work related injury and then the claim would need to go to the Medicare fiscal intermediary to be handled as a secondary payer by the FI in order for Medicare to pay their part of the worker's comp injury as well as a primary payment for Medicare covered items and services not related to the worker's comp injury.

Question: I want to terminate my RHC status, what do I do?

Answer: Owners of RHCs that want to terminate their status as a federally certified rural health clinic will need to consider several things before carrying out their decision ….

If you are selling your business and the RHC status to a new owner, you will need to complete a change of ownership packet (CHOW) which can be obtained from the state surveyor’s office that handles your clinic. Contact them!

If you are just dropping your status as a RHC but will continue as a fee-for-service provider, you will need to notify CMS of your intent to stop services as a RHC. Notify CMS through your state surveyor’s office. Contact your Medicaid provider representative for instructions on terminating services as a RHC with all of their programs.

If you are shutting down the business completely and not going to practice medicine any more, you need to notify a lot of people: that list will include Medicare, Medicaid, the physician’s medical examiners board, and your commercial insurers that you have participation contracts to provide network services for their members.

And don’t forget, a final cost report will have to be made to close out your RHC payment status. Download more specific information here (.pdf).

Question: Is there an example of a planning disaster guide that our clinic can use to prepare for how we will operate in response to a natural disaster, wide-spread infectious disease outbreak, or bioterrorism event in our community?

Answer: There are several guides you can use. I recommend you look at two-
The Texas A&M School of Rural Public Health, in coordination with a number of rural health interest groups, created a guidance document in 2005 for RHCs, FQHCs, and EMS services to use in the development of regional emergency response plans for rural healthcare systems This guidance document is on the school's website and can be downloaded for clinics to adapt for their own use.

www.srph.tamhsc.edu/centers/osp/USACenter/index.htm

For Pandemic Flu planning, the U.S. Department of Health and Human Services (HHS) and the Centers for Disease Control and Prevention(CDC) have developed a checklist to help medical offices and ambulatory clinics assess and improve their preparedness for responding to pandemic influenza.The checklist www.pandemicflu.gov/plan/medical.html and further pandemic flu information can be found at www.pandemicflu.gov .

Question: I want to apply to become a RHC, how do I do that?

Answer: You can become a RHC if you are in a rural area(county ) that is designated as a shortage area, either a Health Professional Shortage Area (HPSA) or a Medically Underserved Area (MUA) which you can check by going to the TARHC website's resource page and linking on to either the state webpage or the Federal webpage, the links will have HPSA and MUA on their lines. Just as a note, to become a RHC you will have to have a midlevel practitioner on staff, meaning a PA, NP, or certified midwife employed in the clinic at least 50% of the time it is open to see patients.

The process of applying to become a RHC is handled through the Texas Department of State Health Services (DSHS) by their Facility Licensing and Compliance Division that has Zone offices around the state and there is a link to that Division on the TARHC website resource page that also has the addresses of the Zone offices.. You will need to contact their Zone office that is responsible for your part of the state to apply for RHC certification. They do a lot of their application distribution of required forms on the Internet but this is basically what you will hear from them...you will be directed to go to the CMS website (or TrailBlazer) to obtain a provider enrollment form (Form CMS -855A) remember the RHC is a facility and gets paid by Part A Medicare, so don't go to the Part B section and get that enrollment form. You will have to also get a NPI number for the rural health clinic that you will list on the CMS-Form 855A . So get the NPI first and then do the 855A form. Once the 855A enrollment form is completed, you need to mail it to the fiscal intermediary (FI).

The FI will process their part of this application and once they have done their part of the process, they will send the approved CMS Form 855A to the Zone office for your area.

Once the state Zone office receives the approved Form 855A from the FI, they send a letter to you informing you that they received the FI approval and request you sent them a letter stating when you are ready for the survey and have provided services to at least five patients. The Zone office will also direct you to the Government Printing Office (GPO) website to obtain a copy of the Conditions for Certification (42 CFR 491, Subpart A) and to the CMS website to obtain copies of the survey report form (Form CMS-30) and the interpretive guidelines. When the Surveyor goes on site, they obtain a request to establish eligibility (Form CMS-29), three original, signed copies of the health Insurance Benefit Agreement (Form CMS-1561A), Office of Civil Rights (OCR) forms which are in Appendix G of the State Operations Manual.

This entire process is not a quick procedure, it may take anywhere from three months,but normally six months to get certified. But some have taken almost an actual year in some cases, and if any part of the process is not completed correctly or caught in a log jam, the wait to get certified seems to never end. So be patient but ask questions all along the way....don't sit and think you are being taken care, ask those questions!

Question: Has anyone looked at how RHCs are doing after the states implemented their Medicaid prospective payment system encounter rates to pay RHCs?

Answer: The Government Accounting Office (GAO) submitted a report to Congress in June of 2005 about their findings of Health Centers and Rural Clinics with State and Federal implementation issues for Medicaid's prospective payment system that is very informative as to how the PPS had been implemented by a number of states.
The report is GAO-05-452 http://www.gao.gov/new.items/d05452.pdf

Question: Where do I find the rules on how Texas Medicaid pays RHCs?

Answer: The rules on how Texas pays the RHC Medicaid Prospective Payment System (PPS) encounter rate can be found in the Texas Adminstrative Code at www.sos.state.tx.us. You can reach it by going through these parts to get to the RHC Reimbursement information.

Title 1 Administration
Part 15 Texas Health and Human Services Commission
Chapter 355 Reimbursement Rates
Subchapter J Purchased Health Services
Division 6 Rural Health Clinics
Rule 355.8101 Reimbursement

Question: I want to set up a new rural health clinic but I have heard that we cannot do that in Texas anymore, is it because we have too many RHCs?

Answer: We do have a problem in Texas for initial certification of new RHCs but it is not because we have too many clinics, the problem is a financial one from the CMS budget standpoint. There simply is not enough money to contract with the state health department to carry out all the functions that must be done for the Medicare program, and it is different for each state... Texas is going through what other states have experienced in the past...and now as a result of prioritizing initial facility surveys (certification inspections for participation in the Medicare program) Rural Health Clinics have been given a very low priority. An exception can be made if there is no access for healthcare to Medicare beneficiaries in that area where someone wants to establish a RHC....but consideration for an exception will have to be determined by the state surveyor who will then make a recommendation to the CMS Regional office in Dallas for consideration if it truly is a situation of no healthcare available to beneficiaries in that location. See the attached correspondence dated November 5, 2007 on this priority designation status for initial RHC surveys. Download CMS correspondence for more information... (Word)

Question: I heard that CMS is gonna change some rules for RHCs, what are they?

Answer: CMS published their new RHC Rule proposal in the Federal Register which can be viewed at http://federalregister.gov/OFRUpload/OFRData/2008-13280_PI.pdf . Public comments must be submitted by 5:00pm Eastern time on August 27, 2008. You can download the slides that were used at a RHC Technical Assitance Conference Call on July 8, 2008 that addresses the proposed RHC changes here: Download the Slideshow (PowerPoint)

Texas Association of Rural Health Clinics
P.O. Box 14547
Austin, Texas 78791
512-873-0045