Rural Health Clinic (RHC) Productivity Standards Exception - JE Part A

Background

Productivity standards help figure out the average cost per patient for Medicare reimbursement in Rural Health Clinics (RHCs). Right now, the standards require full-time doctors to have 4,200 visits a year and non-physician practitioners (like nurse practitioners, physician assistants, and nurse-midwives) to have 2,100 visits a year. Doctors and non-physician practitioners' visits can be combined. The report only counts time spent seeing or scheduled to see patients, not administrative time.

The Medicare Administrative Contractor (MAC) can make exceptions to these standards based on individual situations. All types of patient visits (Medicare, Medicaid, Managed Care, etc.) are considered in the productivity standards for the cost report.

At the end of the year, the MAC recalculates the average reimbursement rate (AIR) by dividing the total allowable costs by the number of patient visits. If the clinic had fewer visits than expected, the MAC uses the expected number of visits instead, which usually lowers the AIR.

Short-term or irregular physician services under agreements are not subject to productivity standards. Instead, they're limited by what Medicare would pay under the Physician Fee Schedule. Practitioners working regularly are subject to productivity standards, no matter if they're employees or contractors.

RHC Productivity Standards Checklist

CMS Pub. 100-02, Chapter 13, Section 80.4 allows for providers to request an exception to these minimum standards, subject to the MACs discretion. We have created a checklist as a guide to address some of the more common situations that, taken in combination, may potentially be considered adequate for an exception to these standards. This checklist should not be construed as a guarantee that any individual criterion, or combination of criteria, will result in approval. The Rural Health Clinic (RHC) Productivity Standards Exception Checklist can be found on the Audit and Reimbursement Forms page and can be submitted to RHC-Productivity-Exceptions@noridian.com.

Note that the manual does not include a specific time frame on when these RHC Productivity Standard Requests should be submitted by the provider, nor does it include a required timeframe for review and approval by the MAC. If the RHC Productivity Standard Request is submitted after the start of the desk review, the results may not necessarily be incorporated into that final settlement. In such a case, the additional documentation can be submitted as part of a request for consideration of a reopening. Ultimately, the decision to reopen or not will be left up to the MAC.

COVID-19 Public Health Emergency (PHE) RHC Productivity Standards Exception

CMS wants to minimize the burden on RHCs who have experienced disruptions in staffing and services and have had difficulty in meeting productivity standards due to the COVID-19 public health emergency (PHE). On May 11, 2023, the COVID-19 PHE ended, and as a result, the RHC productivity standards PHE exception is only available for cost reports beginning before this date. If you would like to request relating to the COVID-19 PHE exception, please send your request to RHC-Productivity-Exceptions@noridian.com. In your request, please include your facility name, provider transaction access number (PTAN), cost reporting period, and an explanation for your request.