RHCs and FQHCs are finally the winners in the yearly battle for better CCM Reimbursements
When Medicare began the CCM (Chronic Care Management) program in 2015, practices everywhere benefited from profitable new incentives for managing their chronic Medicare patients.
But if you were an FQHC (Federally Qualified Health Center) or RHC (Rural Health Clinic), you weren’t permitted to participate in CCM during its first year. The reasoning at the time was related to the unique payment structure for these groups. Fortunately, Medicare finally opened the CCM program to FQHCs and RHCs in January of 2016. The restrictions were significantly tighter however and didn’t allow for 3rd-party groups to assist with CCM. Practices were also required to provide 24/7 access to care directly from the provider or direct staff. The logistics of this made CCM extremely difficult for these groups.
In 2017, Medicare rolled-back those tighter restrictions. For the first time, FQHCs and RHCs had the same CCM program as their FFS (Fee for Service) counterparts, right? Well, not exactly. Medicare added additional levels of reimbursements at the 60-minute level and each 30-minute increment beyond that. So if you had a patient that required Complex CCM services, every practice except FQHCs and RHCs could bill for the extra time using the following codes:
- 99490 for 20-minute CCMs (pays around $42)
- 99487 for 60-minute CCMs (pays around $90)
As you can imagine, this continuous trend has become very frustrating for these groups. When Medicare held their open comment period for 2018, FQHCs and RHCs were very vocal. Nathan Baugh, Director of Government Affairs for the National Association of Rural Health Clinics (NARHC), argued on behalf of the RHCs in their organization. He shared his comments with us:
The NARHC argued to CMS that it was unfair to limit RHCs (and FQHCs) to simply the 20-minute CCM code while their FFS peers could bill for 60-minute and add-on CCM codes. CMS agreed and the conversation turned to how to create that payment equity. We initially proposed that CMS allow RHCs to bill the various levels and receive payment accordingly. However, CMS wanted there to only be one RHC CCM payment for sake of simplicity. – Nathan Baugh
In November of 2017, Medicare announced their final ruling for 2018:
RHCs and FQHCs are paid per-visit rates that are not adjusted based on the complexity of a service or the time spent furnishing services, and the payment rate is not designed to be equal to the payment under the PFS for a specific service. We sought to develop a methodology for payment of care management services that is consistent with the RHC and FQHC payment principles of bundling services and not paying for services based on time increments.
The end result is one new procedure code: G0511. This code can be used for 20 minutes of CCM time each month. G0511 pays around $62. (99490 will no longer be billable for FQHCs and RHCs after December 31, 2017)
In our opinion, this gives FQHCs and RHCs the upper hand for the first time since the beginning of the CCM program in 2015. For example: When an RHC spends 25 minutes on a CCM patient, they will now be receiving around $20 more per patient than their FFS counterparts.
In light of these new changes, our recommendation is that every FQHC and RHC begin these programs immediately. If there are 200 patients in the CCM program, that will generate $12,000 per month in new revenue. This is really a no-brainer. The new changes go into effect on January 1, 2018.
Daniel Godla is the Founder and CEO of ThoroughCare. ThoroughCare specializes in providing simple Chronic Care Management Software for practices to manage their CCM programs. To learn more about ThoroughCare's software solutions for FQHCs and RHCs, schedule a demo today.