NARHC-News: published quarterly                   Your RHC News Source                  Summer 2015 Edition
Rural Health Clinics

Telemedicine Policy


Hall of Fame pitcher Greg Maddox once said "when I stopped trying to strike out hitters, I began to strike out more hitters." Sometimes intense focus on one aspect of what you are doing can cause you to lose sight of the overall picture. In federal healthcare policy, because Medicare & Medicaid are significant drivers of the national debt, there is a strong emphasis on keeping costs low. While well-meaning, this emphasis can sometimes prevent smart policies from ever becoming a reality. Telemedicine is a victim of this phenomenon.

There is a plethora of evidence that telemedicine improves clinical outcomes in cost effective ways. For example, a recent telemedicine demonstration from Confluence Health in central Washington used "Health Buddy" electronic devices to deliver chronic care and was a widespread success. The results were resoundingly positive as Confluence saw ER visits decrease 18%, SNF days decrease 42% & outpatient visits increase 18%. Private insurance companies have recognized the potential of telemedicine & are aggressively expanding their coverage of the service. Despite the surmounting evidence of its benefits, Congress has been slow to properly legislate this issue. Medicare & Medicaid lag behind the private market on telemedicine coverage & state licensing boards have stymied inter-state telemedicine, limiting most telemedicine providers to their home state. 
read more 

Bill Introduced to Improve

Medical Payment Models


Background: The Medicare Shared Savings Program (MSSP) was created by the Affordable Care Act (ACA) to push forward a new payment model that emphasizes quality of care over the quantity of services. Under MSSP, if care is provided below the cost of the traditional fee-for-service model, the providers are rewarded with a portion of the savings. The intent is to lower health care costs without sacrificing quality of care. Only Accountable Care Organizations (ACOs) are able to participate in MSSP. 


Problem: According to CMS' Shared Savings and Losses and Assignment Methodology, "to be eligible for assignment to an ACO, a beneficiary must have had at least 1 primary care service furnished by a physician participating in that ACO." This provision fails to recognize the ability of nurse practitioners, physician assistants, and clinical nurse specialties to provide primary care services. As a result, beneficiaries are not eligible for assignment to an ACO if the primary care service is provided by a health professional other than a physician.    read more

2015 NARHC Fall Institute

The RHC Conference --  15 Breakouts, 22 Sessions


AGENDA: Starting a New RHC; Maximizing Front End Collections; Survey & Cert; 

Legislative Update; RHC Change of Ownership Status & CHOWs; Telemedicine;

RHC Billing 101 and Advanced; 7 Provider Based Requirements; Task Management; Cost Reports 101 and Advanced; How to Manage A Small Practice; ICD-10-now what?

Top HIPAA Hazards & How to Avoid Them; Updates to Shortage Areas; Annual Evaluation & Peer Review, Going Beyond the Requirements;  Meaningful Use 1, 2, & 3 - Conquering Your MU Challenges!; etc.   read more

What's New? 

To achieve better care for patients, the Centers of Medicaid & Medicare Services (CMS) Innovation Center has developed several new models for healthcare delivery. The Accountable Care Organization (ACO) is one of these. The several types of ACO programs offered by CMS differ based on the providers they involve & their targeted service areas. 


One of the newest ACO initiatives offered by CMS is the ACO Investment Model (AIM). The ACO Investment Model is designed to encourage new ACOs to form in rural/ underserved areas, & to encourage existing ACOs to move to high risk tracks. CMS expects that the financial support provided to these ACOs will assist them with the infrastructure investment necessary for improving Medicare beneficiaries' care. read more 

Candidates Wanted for 3 openings 


3-Year Term: January 2016 - December 2018. Candidates must be a current NARHC member. The ideal candidate will have leadership ability and extensive Rural Health Clinic knowledge. The candidate will assist in growing the NARHC Association Membership by being an advocate and it is hoped that he/she will cultivate a relationship with their particular State Association. We prefer candidates be located in a state not already represented on the Board.

TIME COMMITMENT:  Board members are expected to attend the 2 NARHC conferences (2 days long in March & October) and be present on 1-hr./mo. conference calls. Additionally, members should plan to serve on the occasional subcommittee. Time commitment is usually 2-4 hrs/mo. read more  


Learning From Our Coding Mistakes



As we find ourselves closer and closer to October 1, 2015, with no substantial evidence of another pending delay, we are all trying to earnestly transition from ICD-9 to ICD-10 as we prepare ourselves for yet another mandated change. One of the biggest obstacles that we will face during ICD-10 implementation is learning from the ICD-9 coding errors that we discover as we are converting our most common codes to ICD-10. 


I promise you we have been making a lot of coding mistakes in ICD-9 albeit neither intentionally or maliciously. I am not throwing stones here. Many of our systems were not sophisticated products or processes when we first started using them. Also, our providers have been thrown into the coding world by EHR implementation. We have had a big learning curve all the way around. However, as we move forward, we may benefit from a broader understanding of coding principles and guidelines, factors which become even more important with the increased specificity of the codes in ICD-10.   read more  

Behavioral Health in the RHC 


In a previous life, I was the founding Executive Director of a Youth and Family Counseling non-profit organization with a caseload of 40 clients. With this background, I value the provision of behavioral health services in the RHC. Community members may recognize the car or bicycle sitting in the RHC parking lot, but no one will know if the patient is there for their physical or mental health needs, thus greatly reducing the stigma that can be attached to seeking help with emotional/behavioral issues.

However, while you can be reimbursed by Medicare & Medicaid for behavioral health services provided by a LCSW (Licensed clinical social worker--not just a MSW), or a PhD clinical psychologist, neither the licensed marriage & family therapist (LMFT) nor the licensed addiction counselor (or substance abuse counselor) is considered a reimbursable provider in the RHC. This limits your ability to find & pay for a qualified counselor in your clinic.    
read more  

Top 10 Service Pricing Learnings


1)    Be aware of your current competitors and their market position, price-sensitive services (typically higher cost and non-urgent services), and relative risk of volume shifts (possible opportunity for steerage).


2)    Be aware of your emerging competitors and their market position, price-sensitive services, and relative risk of volume shifts. These shifts are real-particularly from Walgreens, CVS, and other retail outlets providing urgent care and chronic care management services, as well as from freestanding imaging providers that may be 30 to 60 miles away-close enough for your patients to drive for non-urgent services to save $500 or more. Insurance companies are encouraging the shift.  read more 

The Anatomy of Risk


We all know that conducting a risk analysis is required for Meaningful Use attesting providers as well as to comply with HIPAA. Knowing that it is required is the easy part, understanding how to conduct a risk analysis, knowing where to start is a bit harder. 

A risk analysis is a mathematical (stop cringing - it's a really simple formula):

Risk = (Threats X Vulnerabilities X Impact) - Controls

There are several variations of this formula; however, this is the simplest way to view risks. This formula will work in most organizations.


If you view each term in relation to your home versus your technical environment, it is much easier to understand. A threat is an external force - like an intruder or severe weather - that has the potential of causing harm to your environment.  A vulnerability is a weakness - like windows/doors, or open Wi-Fi - that could allow a threat access to your environment if not properly managed. Impact is the cost - whether financial, operational, legal, or reputational - if the threat is able to exploit a vulnerability. Controls are the procedures & effort spent to minimize the likelihood of a threat having the ability to exploit a vulnerability as well as controlling the impact to your environment.  read more  
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NARHC Fall Institute
Oct. 27-29, 2015 (T-Th)
Renaissance Grand
St. Louis, Missouri
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