The HRSA Health Center Program and Medicare Site …...FQHC Medicare Enrollment •Each health center site must separately enroll through Medicare to receive FQHC designation •To

The HRSA Health Center Program and Medicare Site Enrollment 

NACHC Policy and Issues Forum

March 29, 2019

Matt Kozar, Director, Strategic Initiatives and Planning DivisionOffice of Policy and Program DevelopmentBureau of Primary Health Care (BPHC)Health Resources and Services Administration (HRSA)

What is an FQHC?

FQHC

Health Center Program awardee

Health Center Program look‐alike

Entities that are outpatient health programs or facilities operated by a tribe or tribal organization under the Indian Self‐Determination Act or by an Indian organization receiving funds under Title V of 

the Indian Health Care Improvement Act

HRSA

Medicare ‐ Social Security Act §1861(aa)(4) and Medicaid ‐ §1905(l)(2)(B) respectively define the “Federally Qualified Health Center” (FQHC) provider type.

2

FQHC Medicare Enrollment

• Each health center site must separately enroll through Medicare to receive FQHC designation

• To enroll, an entity must:  Submit a complete application package (Form CMS‐855A and supporting 

documents) to the appropriate Medicare Administrative Contractor (MAC) Receive from the appropriate CMS Regional Office a CMS Certification Number, a 

signed Medicare agreement, and an effective date

3

Streamlining Medicare FQHC Site Enrollment for Health Centers (1/3) 

• HRSA and CMS collaborating to streamline FQHC enrollment for health centers   Since early 2017 CMS and HRSA have collaborated How can we share information that we both gather during our approval processes?

• Streamlining should lead to quicker approval of sites and provide health centers with the needed reimbursement to serve their patient populations

4

Streamlining Medicare FQHC Site Enrollment for Health Centers (2/3)

• HRSA will routinely provide CMS with health center site data to pre‐populate the Provider, Enrollment, Chain and Ownership System (PECOS)

• Health centers can upload supporting data into PECOS

• After health center validates information in PECOS, CMS will review and approve sites

• The goal is to reduce health center burden and incentivize health centers to use PECOS

• Health centers will also be able to validate currently enrolled site information in PECOS 

5

Streamlining Medicare FQHC Site Enrollment for Health Centers (3/3)

• CMS plans to launch the system upgrade in PECOS in April 2019

• HRSA will conduct a webinar on April 24 with CMS to walk through the process

• Information will be forthcoming through the Primary Health Care Digest  Register for the Digest: 

https://public.govdelivery.com/accounts/USHHSHRSA/subscriber/new?qsp=HRSA‐subscribe

6

Thank You!

Matt Kozar, Director, Strategic Initiatives and Planning DivisionOffice of Policy and Program DevelopmentBureau of Primary Health Care (BPHC)Health Resources and Services Administration (HRSA)

[email protected]

(301) 594‐4300

bphc.hrsa.gov

Sign up for the Primary Health Care Digest

7

Connect with HRSA

To learn more about our agency, visit

www.HRSA.gov

Sign up for the HRSA eNews

FOLLOW US:

8

2019 Medicare FQHC Payments

National Association of Community Health Centers

Policy & Issues Forum

CAPT Corinne AxelrodMarch 29, 2019

Objectives

Review Medicare payment for FQHC services

Develop a better understanding of care management services and billing

Learn about the new payment for virtual communication services

Provide feedback to CMS on Medicare FQHC payment and policy issues

Information & Questions

Information on the Medicare FQHC Program:

https://www.cms.gov/Center/Provider-Type/Federally-Qualified-Health-Centers-FQHC-Center.html

Questions on Medicare FQHC Payment and Policies: [email protected]

CMS Medicare FQHC Payment Policy Contacts

Lisa Parker, JD [email protected]

Glenn McGuirk [email protected]

Corinne Axelrod, [email protected]

FQHC Medicare Payment 1991 - 2014

Medicare Fiscal Intermediaries calculated a per-diem rate for each FQHC

Divided total allowable costs by the number of total visits

Subject to productivity standards

FQHC Medicare Payment 1991 - 2014

Subject to a payment cap Rural (2013 – approx. $111)Urban (2013 – approx. $128)

Subject to annual reconciliation Increased annually based on the

Medicare Economic Index (MEI)

FQHC Medicare Payment –Affordable Care Act (ACA) 3/23/2010 - ACA signed into law, required the

development and implementation of a Medicare Prospective Payment System (PPS) for FQHCs

Initial PPS rate must equal 100% of the estimated amount of reasonable costs that would have occurred for the year if the PPS had not been implemented, without the application of copayments, per-visit limits, or productivity adjustments

FQHC Medicare PPS

1/1/2011 – FQHCs required to use HCPCS* coding on claims for use in the development of the PPS

9/23/2013 – Medicare FQHC PPS Proposed Rule

5/2/2014 – Medicare FQHC PPS Final Rule 10/1/2014 – 12/31/2015 - FQHCs

transitioned to the new Medicare PPS

*Healthcare Common Procedure Coding System

FQHC Medicare PPS Rate

National Rate

First year (2015)- $158.85

Rate adjusted annually based on an FQHC Market Basket data

Current year (2019) - $169.77

FQHC Medicare PPS -Payment FQHC payment is the lesser of the FQHC’s

charge for the specific payment code or the PPS rate PPS rate is adjusted by the FQHC GAF

(geographic adjustment factor) FQHC payment is adjusted for new patient* visit,

AWV, or IPPE (34%)*A new patient is someone who has not received any Medicare-covered professional health service (medical or mental health) from any site within the FQHC organization, or from any practitioner within the FQHC organization, within the past 3 years from the date of service.

FQHC Medicare PPS –Payment Codes

G Codes required to bill for a FQHC visit(including Medicare Advantage plans)

G0466 – Primary care, new patientG0467 – Primary care, established patientG0468 - IPPE or AWVG0469 - Mental health, new patientG0470 - Mental health, est. patient

FQHC Medicare PPS –G Codes FQHCs set their charge for the specific payment

codes (G0466-G0470) based on their determination of what would be appropriate for the services normally provided and the population served, and the description of services associated with the payment code

The charge should reflect the sum of the regular rates charged for a typical bundle of services that would be furnished per diem to a Medicare beneficiary

CMS does not dictate to FQHCs how to set their charges

FQHC Medicare PPS –Claims

Must contain a G code (G0466-G0470), HCPCS code, and a revenue code

FQHC PPS Specific Payment Codes (https://www.cms.gov/Center/Provider-Type/Federally-Qualified-Health-Centers-FQHC-Center.html)

FQHC Billable Visits

Face-to-face (one-on-one) medically-necessary medical or mental health visit, or a qualified preventive health visit, between the patient and an FQHC practitioner during which time one or more FQHC services are rendered, and

Only services that require the skill level of the FQHC practitioner are considered FQHC billable visits

FQHC Medicare Payment

Payment includes all services and supplies furnished incident to the visit

One billable visit per day, except for subsequent illness/injury, mental health visit, or IPPE visit

Payment for Certain New Medicare Services Payment for certain new services

that do not meet the requirements for a stand-alone billable visit and are not included in or incident to a stand-alone billable visit

Payment for Certain New Medicare Services General Care Management

Services

Psychiatric Collaborative Care Management Services

Virtual Communication Services

Payment for Certain New Medicare Services

General Care Management Services CCM (Chronic Care Management) General BHI (Behavioral Health Integration)

General Care Management ServicesCPT 99490* (> 20 min. of CCM services directed

by an FQHC practitioner, per calendar month)CPT 99487* (> 60 min. of CCM services of

moderate to high complexity, directed by an FQHC practitioner, per calendar month)

CPT code 99491* (>30 min. of CCM services furnished by an FQHC practitioner, per calendar month)

CPT code 99484* (>20 min. of general BHI services, directed by an FQHC practitioner, per calendar month)

*FQHCs do not bill these codes

General Care Management - Payment Payment set at the average of the PFS national,

non-facility payment rate for the 4 codes 2019 Payment Rate - $67.03 per beneficiary

per month Must use G0511 on claim No waiver on coinsurance and deductibles Billed alone or with other payable services Payment rate updated annually based on the

PFS amounts for applicable codes

G0511 - Eligibility

CCM - 2 or more chronic conditions expected to last >12 months or until the death of the patient, and place the patient at significant risk of death, acute exacerbation or decompensation, or functional decline, or

General BHI - Any behavioral health or psychiatric condition being treated by the FQHC primary care practitioner, including substance use disorders, that, in the clinical judgment of the FQHC primary care practitioner, warrants BHI services

G0511 Requirement -Initiating VisitA separately billable

Evaluation/Management (E/M), Annual Wellness Visit (AWV), or Initial Preventive Physical Exam (IPPE) visit

Occurring no more than one-year prior to commencing care management services

Furnished by a primary care physician, NP, PA, or CNM

G0511 Requirement -Consent Obtained by the FQHC practitioner or auxiliary

personnel before the provision of care management services

Written or verbal, documented in the medical record Includes information on the availability of care

coordination services and applicable cost-sharing, that only one practitioner can furnish and be paid for care coordination services during a calendar month, that the patient has the right to stop care coordination services at any time, effective at the end of the calendar month, and that the patient is giving permission to consult with relevant specialists

G0511 Requirement -Services Directed by the FQHC primary care

practitioner, who remains involved through ongoing oversight, management, collaboration and reassessment

Furnished by an FQHC practitioner or by clinical personnel under general supervision

Specific service requirements for CCM and for general BHI (see Chapter 13 of the Medicare Benefit Policy Manual)

CCM in FQHCs

Total Beneficiaries

Total Payment

Top 5 States

2016 2,532 293,352 NC, KY, CA, MA, GA

2017 11,403 1,654,549 CA, SC, NC, GA, AR

2018 31,527 6,738,984 CA, SC, NC, WV, NY

Payment for Certain New Medicare Services

Virtual Communication Services

Virtual Communication Services - Requirements

>5 minutes of communication technology-based or remote evaluation services are furnishedby an FQHC practitioner to a patient who has had an FQHC

billable visit within the previous year, AND

Virtual Communication Services - Requirements

The medical discussion or remote evaluation is for a condition not related to an FQHC service provided within the previous 7 days, and

The medical discussion or remote evaluation does not lead to an FQHC visit within the next 24 hours or at the soonest available appointment

Virtual Communication Services - Payment

Payment set at the average of the PFS national, non-facility payment rate for these 2 codes: HCPCS code G2012* (communication

technology-based services) HCPCS code G2010* (remote

evaluation services)* FQHCs do not bill these codes

Virtual Communication Services - Payment Effective 1/1/19 2019 Payment Rate - $13.69 per service No frequency limitations Must use G0071 on claim No waiver on coinsurance and deductibles Billed alone or with other payable services Payment rate updated annually based on

the PFS amounts for applicable codes

FQHC Medicare Payment Policies

Questions???

Medicare CCM for FQHCsIndiana Quality Improvement Network

March 29, 2019

Agenda

Introduction to the Indiana Quality Improvement Network

Transformation toward the Quadruple Aim

Health Center Challenges

Medicare CCM Opportunity

Lessons Learned  

Who are we?• PCA‐Based Health Center Controlled Network

• 26 Participating Health Centers

• Governed by HCCN Committee of the PCA Board of Directors

One Network, Varied Capacity

A Unified Vision

Risk Stratification Age Ranges End Age # PatientsPediatric 21 34035Adult 65 50048Geriatric 7688

Category Prevalence ThresholdPediatric High 3.6% 7Pediatric Moderate 19.8% 3Pediatric Low 76.6% 0

Category Prevalence ThresholdAdult High 4.7% 14Adult Moderate 20.2% 8Adult Low 75.1% 0

Category Prevalence ThresholdGeriatric High 7.1% 14Geriatric Moderate 21.2% 9Geriatric Low 71.7% 0

AGE‐BASED THRESHOLD FOR RISK STRATIFICATION

Geriatric Thresholds

Adult Thresholds

Pediatric Thresholds

Age Definitions

NACHC Value Transformation Framework: Risk Stratification Action Guide:http://www.nachc.org/wp‐content/uploads/2018/02/Action‐Guide_Pop‐Health_Risk‐Stratification‐Sept‐2017.pdfAAFP Risk Stratified Care Management Rubric:https://nf.aafp.org/Shop/practice‐transformation/risk‐stratified‐care‐mgmt‐rubric

Managing High Risk & High Cost Patients

Challenges

Medicare ACO

Health Home 

Payments

Alternative Payment Models

Care Management 

PMPM

Care Management 

Staff

Health Center Grit

Opportunity Knocks

•Medicare CCM Billing Code G0511 available to FQHCs and Look‐Alikes•$62.28 PMPM for 20 Minutes of Care Management•Aligned with our desire to build sustainable care management capacity

Medicare Patients

• 8.2% Medicare• 41,600 Medicare Patients

• 7% High Risk• 21% Moderate Risk

• 200 patients x 6 months of CCM = $74,736

Our Population Health Approach

Great Lakes Practice Transformation Network Partnership

Recruited 10 Health Centers (5 GLPTN/5 IQIN)

Focus on Diabetics with at least one other Chronic Disease

Our Implementation Approach

Billing Training

Quality Improvement Model: Lean Daily Improvement

American College of Physicians Chronic Care Management Toolkit: What Practices Need to Do to Implement and Bill CCM Codes*

Care Coordination and Care Management Training

*https://www.acponline.org/system/files/documents/running_practice/payment_coding/medicare/chronic_care_management_toolkit.pdf

The Method – Lean Daily Improvement

Training

• 1 health centers completed

LDI

• 3 certified• 10 in progress• 5 waiting to launch

Processes

• ID eligible patients• Consent/enrollment• Educate providers and care teams

• Daily huddles

Tools

Electronic Health Record

• Generating Lists of Eligible Patients

• Chronic Care Management Modules

Azara DRVS

• Risk Stratification Registry

• Care Management Passport

• Cohorts to track improvement in HbA1c Control

• Care Manager

Other

• Practice Analytics• Spreadsheets

CCM Progress

Identify

• Pulling patient lists

• Internal processes

Enroll

• > 300 Patients• Documentation• When to call

Bill

• > 300 Patients• >550 Claims• >$40,000 charges

• <$1,000 paid

CCM Activities

Medication Reconciliation

•Medication refills

• Medication literacy

• Dosage changes

Behavioral Goals

• Diet• Physical Activity

• Self management

Care Coordination

• Referrals• Transitions of care

• ED visits discussions 

SDOH

• Screening• Referrals• Employment

Success Stories

Social Determinants Solutions

Education for Self‐Management

Protecting Livelihoods

Barriers

Organizational Readiness

EHR limitations

Don’t want patients to have co‐pay burden

Indiana Medicaid not paying co‐pay for Dual‐eligible

Working through billing kinks

Contact

Angela BoyerHCCN Director, Indiana Quality Improvement [email protected]‐983‐1002Indiana Primary Health Care Association429 N. Pennsylvania St., Ste. 333Indianapolis, IN 46204