CRHC cheat sheet

RHC must be located in a non-urbanized area (Census Bureau definition) or a designated health professional shortage area (HPSA) to qualify for Medicare certification.

RHC must employ a nurse practitioner, physician assistant, or certified nurse midwife at least 50% of the time the clinic operates, and a physician must supervise.

RHC certification requires compliance with 42 CFR Part 491; survey via State Survey Agency using the RHC survey protocol.

RHC must have a written policy for providing services in a culturally competent manner and ensure services are provided in a language the patient understands.

RHC must be primarily engaged in providing outpatient primary care services; inpatient services are not covered.

RHC must have a health care professional available to furnish services during all hours the clinic is open.

RHC must have a quality assessment and performance improvement (QAPI) program as a condition for participation.

RHC must post a notice of its hours of operation and after-hours contact information.

Medicare pays RHCs an all-inclusive rate (AIR) per qualifying visit, subject to a per-visit payment limit; the AIR is adjusted annually by the Medicare Economic Index (MEI).

Qualifying visits include those furnished by physicians, NPs, PAs, CNMs, clinical psychologists, and clinical social workers; services must be medically necessary and face-to-face.

RHCs bill Medicare Part A for core services using the 71x bill type; Part B services (e.g., certain vaccines) are billed separately.

Medicare coinsurance is 20% of the AIR after the deductible; Medicaid may cover coinsurance for qualified beneficiaries.

RHCs may use the cost-based method or the standard payment method (if elected) for Medicare reimbursement.

Preventive services like the welcome to Medicare visit and annual wellness visit are covered but may have different payment rules.

RHCs must use appropriate CPT/HCPCS codes for services; incorrect coding can lead to claim denials or recoupment.

Telehealth services furnished by RHCs are reimbursed as if furnished in-person, with the AIR, when conditions are met.

RHC scope of services includes primary care, prenatal care, and other outpatient services; services must be furnished by or under the supervision of an RHC practitioner.

Care coordination includes referrals, discharge planning, and patient education; RHCs must have a process for tracking referrals and ensuring follow-up.

RHCs must have a written plan for handling emergencies, including transfer agreements with local hospitals.

RHCs must maintain a health record for each patient that is accurate, complete, and readily accessible; records must be retained per state and federal requirements.

RHCs must provide services in a manner that ensures patient rights, including privacy and confidentiality (HIPAA).

RHCs must have a process for medication management, including prescribing, dispensing, and reconciliation.

RHCs must have an infection control program that follows accepted standards of practice (e.g., CDC guidelines).

RHCs must comply with the False Claims Act; knowingly submitting false claims can result in treble damages and penalties.

RHCs must have a compliance program that includes written policies, a compliance officer, training, and auditing/monitoring.

RHCs are subject to periodic audits by Medicare Administrative Contractors (MACs) and Recovery Audit Contractors (RACs).

The Office of Inspector General (OIG) Work Plan lists areas of focus; RHCs should monitor for relevant audits.

RHCs must report and return overpayments within 60 days of identification (60-day rule).

RHCs must screen employees and contractors against the OIG List of Excluded Individuals/Entities (LEIE) and the System for Award Management (SAM).

RHCs must adhere to the Stark Law (physician self-referral) and Anti-Kickback Statute; arrangements with referral sources must be reviewed.

RHCs must file an annual Medicare cost report (Form CMS-222-92) within 5 months after the end of the fiscal year.

The cost report determines the AIR and any reconciliation; it must include allowable costs and statistics (visits, charges, etc.).

Revenue cycle management includes patient registration, coding, billing, collections, and denial management.

RHCs must establish financial policies, including charity care and financial assistance, and comply with IRS 501(r) if tax-exempt.

RHCs should monitor key revenue cycle metrics: days in accounts receivable, denial rate, and net collection rate.

RHCs must maintain proper documentation to support charges; lack of documentation can lead to claim denials.

RHCs must ensure proper cost allocation for shared costs (e.g., space, staff) across programs.

RHCs must have an ongoing QAPI program that tracks quality measures and implements improvements.

RHCs should participate in quality reporting programs (e.g., MIPS) if eligible; reporting can affect payment adjustments.

Patient safety initiatives include medication reconciliation, fall prevention, and hand hygiene compliance.

Population health management involves identifying at-risk patients, providing preventive care, and managing chronic conditions.

RHCs should use health information technology (e.g., EHRs) to support quality measurement and improvement.

RHCs must have a process for reporting and investigating adverse events and sentinel events.

RHCs should engage patients in quality improvement through surveys and feedback mechanisms.

RHC must have a governing body that is responsible for the clinic's operations and compliance with regulations.

RHC must have a clinic manager or director with authority to manage daily operations.

RHC must have a written organizational chart and clear lines of authority.

Human resources policies must include credentialing and privileging of practitioners, background checks, and ongoing performance evaluations.

RHC must ensure staff are licensed, certified, or registered as required by state law and have appropriate training.

RHC must have a process for handling personnel issues, including grievances and disciplinary actions.

Leadership must ensure a culture of safety and compliance, including regular communication and training.

RHCs must comply with state licensure laws, which may vary; some states require a specific RHC license.

Medicare certification is obtained through the State Survey Agency (SSA) and CMS; surveys may be announced or unannounced.

RHCs must be prepared for surveys by maintaining documentation, conducting mock surveys, and training staff.

Common survey deficiencies include lack of compliance with conditions of participation (CoPs), inadequate QAPI, and infection control issues.

Plan of correction (POC) must be submitted for deficiencies; failure to correct can lead to termination from Medicare.

RHCs must stay informed about changes in healthcare policy, such as updates to Medicare payment rules and telehealth policies.

RHCs should participate in industry associations and monitor CMS updates for regulatory changes.