Establishing Provider-Based Clinics – Advanced Issues

Event Information
Product Format
Prerecorded Event
90 minutes
Product Description

Review the Provider-Based Rule in Detail and Learn About Some Advanced Topics.

Hospitals around the United States are increasingly establishing provider-based clinics of all types. Although hospitals can enjoy increased revenues from provider-based clinics, complying with all the rules and regulations can be very challenging. The provider-based rule (PBR) is complex with definite ambiguities, and recent changes in the supervisory requirements for provider-based operations have created further confusion and newer compliance challenges.

That’s not all! There has been a movement to change the rules and regulations relative to the reimbursement for provider-based clinics. Do you know what special coding and billing requirements are required for provider-based clinics?

Join expert speaker Duane C. Abbey, Ph.D., in this informative session, where he reviews the provider based rule (PBR) in detail and discusses the advantages to physicians from being in a provider-based clinic. By attending this session, you will learn about the multiple compliance concerns and specific coding and billing requirements for provider-based clinics

Learning Highlights

  • Why do hospitals establish provider-based clinics?
  • What are the advantages to physicians for being in a provider-based clinic?
  • Why are there ambiguities in the provider-based rule (PBR)?
  • Do we have to meet each and every criterion in order to establish provider-based status?
  • Which required criteria present special problems?
  • When is CMS interested in making a determination that an operation is provider-based?
  • What CMS-855 enrollment forms must be completed relative to provider-based clinics?
  • How do the physician supervision requirements affect provider-based status?
  • What special coding and billing requirements are required for provider-based clinics?
  • What if we are outside the 35-mile default limit?
  • What if we have a facility in which part is provider-based and part is freestanding?
  • What if we have space that is used jointly by both the hospital and other providers?
  • What kind of signage is really necessary?
  • How do we report changes in provider-based operations?
  • Should we routinely ask for determinations from out MAC?
  • How do we go about auditing our provider-based operations?
  • Are there differences for provider-based operation in the hospital vs. on-campus vs. off-campus?
  • How have Section 603 of BiBA 2015 and Section 16001 of the 21st Century Cures Act affected provider-based clinics?

Session Highlights

  • The provider-based rule (PBR)
  • The differences between freestanding and provider-based clinics
  • The economic advantages of provider-based clinics
  • The special requirements for provider-based clinics
  • The special compliance concerns associated with provider-based status
  • Coding and billing issues for provider-based clinics
  • How to qualify clinics that are outside the 35-mile default limit?
  • Signage and proper identification for provider-based operations
  • The complicated issues such as joint use of space and time-share space utilization
  • The provider-based reporting requirements and the CMS-855 forms
  • The application of the physician supervision requirement for outpatient services
  • The operation issues such as setting fees, patient relations and medical staff organizational structuring
  • The on-going ambiguities in the provider-based rule affecting provider-based operations
  • The impact of 603 BiBA 2015 and Section 16001 of the 21st Century Cures Act affected establishing provider-based clinics
  • The several case studies involving special issues in the establishment of the provider-based clinics

Session Outline

  • Review of the Provider-Based Rule (PBR)
    • Development of the PBR
    • 42 CFR §413.65
    • Review of Definitions
  • Economic Advantages of Provider-Based Status
    • Clinics
    • Clinical Services
    • Costs for Provider-Based Status
    • Recognizing Provider-Based Clinical Services
  • Establishing Provider-Based Clinics
    • Meeting the PBR Requirements
    • Coding and Billing for Provider-Based Clinics
    • Physician Supervision Requirements
    • CMS 855 Forms
      • CMS-855-B
      • CMS-855-A
      • CMS-855-I
  • Recent Legislation
    • Section 603 of BiBA 2015
    • Section 16001 of the 21st Century Cures Act
  • Special Issues and Sensitivities
    • Split-Billing
      • 1500 Claim Form Requirements
      • UB-04 Claim Form Requirements
    • ‘Holding-Out to the Public” – Proper Signage
    • Split-Use Facilities
    • Time-Share Use of Facilities
    • Cost Reporting Issues
    • Qualifying Clinics that Are Outside the 35-Mile Default
    • Requesting Determinations and Filing Attestations
    • 3-Day Payment Window Issues – Freestanding vs. Provider-Based
    • Affiliated Hospitals and Remote Campuses
    • Related Laboratory and Radiology Issues
  • Case Studies
  • Sources for Further Information

Who Should Attend

  • Charge master personnel
  • Compliance personnel
  • Claims transaction personnel
  • Coding personnel
  • Financial analysts
  • Operating officers
  • Clinic administrators and managers
  • All personnel involved with provider-based clinics and/or clinical operations including nursing staff and interested physicians/practitioners

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About Our Speaker

Duane Abbey Hospital Coding & Compliance Expert

 Duane C. Abbey, Ph.D. is a management consultant and president of Abbey & Abbey, Consultants, Inc., which specializes in healthcare consulting 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. He performs various types of financial analysis involving business structuring, organizational development, enrolment and other financially related concerns of organizations....   More Info
More Events By The Speaker

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