Recent Changes to Provider-Based Criteria Determinations
Kirk Delperdang, Healthcare Director
December 13, 2023
Healthcare providers face numerous challenges when it comes to reimbursement. To avoid obstacles, they must have a comprehensive understanding of provider-based analysis and its impact on Medicare reimbursement. We have witnessed the importance of accurate provider-based determinations and the financial benefits they can bring to healthcare organizations. This article will explore the key aspects of provider-based analysis, the ability of Critical Access Hospitals to continue to meet Conditions of Participation, its potential for increased Medicare reimbursement, and providing health care in areas not previously served.
Understanding Provider-Based Analysis
Provider-based regulations refer to the rules and criteria determining whether a healthcare facility can be considered part of a larger healthcare organization. These regulations are outlined by the Centers for Medicare and Medicaid Services (CMS) in 42 CFR 413.65. The rules help determine the relationship between a main provider and a provider-based entity or department of a provider. They also define the conditions under which a Critical Access Hospital (CAH) can operate an off-campus provider-based facility. Compliance with these regulations is crucial as it affects the reimbursement a facility can receive for the cost of care provided.
CMS periodically updates its rules and regulations to reflect the evolving needs and challenges of the healthcare industry. The recent changes to the provider-based mileage and road definitions are part of this ongoing process of revision and improvement.
Previously, CAHs had to be located more than 35 miles from any other hospital or CAH or more than a 15-mile drive in areas with mountainous terrains or only secondary roads. The new rule specifies that the 35-mile distance only applies to 4-lane highways, while a 15-mile distance applies to 2-lane roads.
The primary purpose of the revised regulation is to enhance healthcare accessibility for rural populations. By adjusting the distance criteria for CAH designation, CMS aims to enable more hospitals to qualify for this status, thereby increasing the number of healthcare facilities available to rural communities.
The Benefits of Provider-Based Determination
Accurate provider-based determinations offer significant benefits to healthcare organizations. Firstly, a provider-based facility or service can receive enhanced reimbursement rates from Medicare, resulting in increased revenue. This additional funding can be critical for maintaining the financial viability of healthcare organizations by investing in resources, staff, and technology, especially in rural areas where resources may be limited.
The Process of Provider-Based Analysis
To make a provider-based determination, healthcare organizations must undergo a comprehensive analysis of their operations, governance structure, financial integration, and clinical services. This process typically involves the following steps:
Assessing Governance Structure
Evaluating the shared governance structure between the main facility and the provider-based entity includes examining the reporting relationships, decision-making processes, and oversight mechanisms.
Financial Integration Analysis
Analyzing the financial integration between the main facility and the provider-based entity involves reviewing financial statements, intercompany transactions, and financial support from the main facility.
Operational Integration Evaluation
Assessing the operational integration between the main facility and the provider-based entity includes examining the coordination of services, shared resources, and the level of clinical integration.
Ensure that all necessary documentation, including legal agreements, bylaws, and policies, supports the provider-based determination. Once the provider-based analysis is complete, healthcare organizations can confidently determine whether a facility or service qualifies for provider-based status.
Facilities or organizations seeking provider-based status must ensure that they are perceived by the public as integral parts of the main provider. Patients should be aware that their entry into such a facility or organization equates to accessing the main provider's services and will be billed as such.
Meeting Critical Access Hospital Conditions of Participation
Critical access hospitals are vital in providing healthcare services to rural communities. To qualify as a CAH, facilities must meet specific Conditions of Participation (CoPs)established by CMS. These CoPs cover various aspects of healthcare delivery, including governance, quality assessment, patient rights, and facility management. However, one crucial aspect that often requires careful consideration is the provider-based analysis.
By meeting the provider-based analysis requirements, CAHs can provide services in locations they may not have been able to before to enhance the overall network of rural healthcare services. This alignment ensures that the CAH is an integral part of a larger healthcare system, providing seamless care coordination and improved access to services for rural residents.
How Lutz’s Healthcare Accounting Services Can Help
Provider-based analysis is a crucial process for healthcare organizations, particularly Critical Access Hospitals, aiming to maximize reimbursement and meet the CoPs. Healthcare leaders must recognize the importance of accurate provider-based determinations and work towards aligning their operations, governance, and financial practices to meet the requirements set forth by CMS.
Responsibility, Arranger, Includer, Harmony, Communication
Kirk Delperdang is a Healthcare Director at Lutz. He began his career in 1993. He provides healthcare enrollment services to clients with a focus on Medicare providers and reimbursement analyses. In addition, he is responsible for leading Lutz's cost report service offering.
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