Advanced Issues in Establishing Provider-Based Clinics

Event Information
Product Format
Prerecorded Event
90 minutes
Product Description

Review the Provider-Based Rule and Make Smarter Choices for Your Hospital and Clinic

Understanding the Provider-Based Rule (PBR) can be a tall order, especially as changes in the physician supervision and reimbursement rules add confusion. Not only do hospitals’ provider-based operations face unique billing and operations issues, but PBR ambiguities—from multiple PBR-status criteria to joint-use/time-share spaces to signage requirements—make compliance a real challenge. Learn to weigh the economic benefits and compliance concerns of provider-based operations—and make smarter choices for your hospital and clinic.

Join expert speaker Duane C. Abbey, Ph.D, as he explains the key differences between freestanding and provider-based clinics, and the economic advantages of the latter. He will teach you to set fees for your clinic, conduct patient relations, and effectively organize your medical staff. Abbey will walk you through all the complex PBR compliance details, including how to: apply the physician supervision requirements for outpatient services , abide by reporting requirements, use CMS-855 enrollment forms, qualify clinics that are outside the 35-mile default limit, and audit your clinic operations.

The 2017 Outpatient Prospective Payment System (OPPS) rule changed how non-exempted off-campus provider-based departments will be paid. And both Section 603 of the 2015 Bipartisan Budget Act (BiBA) and Section 16001 of the 21st Century Cures Act have significantly affected the establishment and payment systems of provider-based clinics. Be sure your clinic is up-to-date and being paid appropriately!

After attending this informative session, you will be well equipped to implement all PBR-specific billing and coding requirements—and be audit-ready at all times. By the end of this information-packed session, you will have the tools you need to understand how federal legislation and billing requirements converge to impact how your clinic will be paid.

Session Highlights

This program will teach you how to:

  • Qualify clinics outside the 35-mile default limit
  • Apply provider-based reporting requirements and fill out the CMS-855 forms
  • Clarify which criteria must be met in order to qualify for provider-based status
  • Improve operations, such as setting fees and structuring staff
  • Gauge how PBR ambiguities may be affecting your operations and how to gain clarity
  • Get started on upgrading your  provider-based clinic’s coding and billing practices
  • Determine how and when to audit your provider-based operations to remain compliant with CMS

Session Objectives:  

In this session you will be able to:

  • Briefly review the Provider-Based Rule
  • Understand the differences between freestanding and provider-based clinics
  • Understand the economic advantages of provider-based clinics
  • Review and appreciate special requirements for provider-based clinics
  • Appreciate special compliance concerns associated with provider-based status
  • Discuss coding and billing issues for provider-based clinics
  • Understand how to qualify clinics that are outside the 35-mile default limit
  • Discuss signage and proper identification for provider-based operations
  • Explore complicated issues such as joint use of space and time-share space utilization
  • Understand provider-based reporting requirements and the CMS-855 forms
  • Explore the application of the physician supervision requirement for outpatient services
  • Discuss operation issues such as setting fees, patient relations and medical staff organizational structuring
  • Review on-going ambiguities in the Provider-Based Rule affecting provider-based operations
  • Analyze the impact of 603 BiBA 2015 and Section 16001 of the 21st Century Cures Act affected establishing provider-based clinics?
  • To work through several case studies involving special issues in the establishment of the provider-based clinics

Session Agenda:

  • Review of the Provider-Based Rule
    • 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

All persons involved with provider-based clinics will benefit from this session, including:

  • Claims transaction and compliance personnel
  • Financial analysts
  • Operating officers
  • Clinic administrators and managers
  • Coding personnel
  • Chargemaster personnel
  • Nursing staff
  • 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
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