Clinical Operations, Scope of Services, and Care Coordination
Scope of services
The RHC must provide outpatient primary care services, including physician services, NP/PA/CNM services, and basic lab and diagnostic services as defined in its patient care policies. The clinic's written policies must describe the services offered, the patient population served, and the mechanisms for referral and follow-up. Candidates should understand that the RHC is not required to offer every service, but whatever it offers must be within its stated scope and supported by qualified staff and equipment.
Care coordination
Care coordination in an RHC centers on the medical home model: the RHC practitioner manages the patient's care, coordinates referrals to specialists, and ensures follow-up. Key concepts include the referral and tracking process, the use of a designated care coordinator, and the integration of behavioral health and chronic-care management. The RHC must have a process for handling emergencies, including arrangements with a hospital or emergency service.
Traps
Questions often test the boundary between RHC scope and hospital services: an RHC cannot bill for inpatient care, and services furnished outside the RHC's four walls are generally not covered unless they meet specific exceptions. Another trap is the assumption that a specialist's visit in the RHC is automatically covered - it is only covered if the specialist is an RHC practitioner and the service is within scope. Also watch for questions about after-hours coverage: the RHC must have a plan, but it need not be open 24/7.
Worked example
A diabetic patient needs an ophthalmology referral. The RHC documents the referral, tracks whether the patient attended, and follows up on the results at the next visit. The RHC cannot bill the specialist's exam as an RHC encounter; it can only bill its own coordinating visit if a face-to-face encounter occurs.
Rule of thumb
If the service isn't furnished face-to-face by an RHC practitioner within the clinic's stated scope, it isn't an RHC encounter.