Hospital-Based Clinics And The Complexities Around Them

A Comprehensive Review Of The Provider-Based Rule (PBR) By Duane Abbey

Hospitals are making efforts to establish provider-based clinics of all types. The provider-based rule (PBR) is quite complex and confusing, and there are definite ambiguities that make it a challenging task.  

Join this informative 90-minute session with Duane Abbey, Ph.D.  to know about the advantages of provider-based clinics to hospitals, the role of the hospitals to establish provider-based clinics, various ambiguities in the provider-based rule (PBR), the art of selecting criteria and meeting the demand to establish a provider-based clinic; and to brace up for the upcoming challenges..

Duane will also focus on explaining different aspects of CMS and why is it interested in making a determination that an operation is provider-based, with the importance of CMS-855 enrollment forms and completion to provider-based clinics.

Session Highlights:

• Coding and billing requirements required for provider-based clinics
• Setting up a proper fee schedule for both the facility and professional components
• 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?
• The kinds of signage
• To report changes in provider-based operations
• Should we routinely ask for determinations from out MAC?

Objectives of the session:

• To review the Provider-Based Rule (PBR)
• To understand the differences between freestanding and provider-based clinics
• To understand the economic advantages of provider-based clinics
• To appreciate special requirements for provider-based clinics
• To appreciate compliance concerns associated with provider-based status
• To discuss coding and billing issues for provider-based clinics
• To understand how to qualify clinics that are outside the 35-mile default limit
• To discuss signage and proper identification for provider-based operations
• To discuss complicated issues such as joint use of space and time-share space utilization
• To understand provider-based reporting requirements and the CMS-855 forms
• To research the application of the physician supervision requirement for outpatient services
• To discuss operation issues such as setting fees, patient relations and medical staff organizational structuring
• To review on-going ambiguities in the Provider-Based Rule affecting provider-based operations
• To work through several case studies involving issues in the establishment of the provider-based clinics

Agenda of the session: 

• Review of the Provider-Based Rule (PBR)
  • Development of the PBR
  • 42 CFR §413.65
  • Review of Definitions
  • Rules and Regulations
  • Recognition by Non-Medicare Third-Party Payers
• 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
• Issues and Sensitivities
  • ‘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
  • Related Laboratory and Radiology Issues
• Case Studies
• Sources for Further Information

Who should attend?

The session is appropriate for Chargemaster personnel, compliance personnel, claims transaction personnel, coding personnel, financial analysts, operating officers, clinic administrators and managers, and all personnel involved with provider-based clinics and/or clinical operations including nursing staff and interested physicians/practitioners.

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