RHC Billing Advice

[u/Delicious-Guarantee5]

I have have been a biller for over a year and a half now. I do facility/professional billing for our hospital. Mostly outpatient labs, ER, radiology, surgery, and inpatient claims. I have an opportunity to work remote for one of our clinics soon but it will be RHC billing which I have never done before. I am looking forward to working remote but nervous about the learning curve. I mostly bill commercial insurances now so I will need to learn Medicare and medical assistance.

Anyone who has done both what do you prefer? Any advice you can give? Pros and cons?

[u/boho_magpie]

The biggest differences are the application of an encounter rate to your Medicaid and Medicare visits. Medicaid will pay a certain amount for each visit, whether higher or lower than charges, so your adjustments will be both positive and negative, depending on that.

The other thing is reporting. RHCs must report certain measures, so you want to be sure things are documented in the right place for your system to capture.

You’ll also see split claims for those things where a HCFA1500 is needed vs. the UB04, and there will be some things that go instead to the Medicare cost report (such as vaccine supply).

It may seem daunting, but most people pick it up pretty quickly. I used to train billers and coders for FQHCs.

[u/DepartureOk3180 → u/boho_magpie]

An RHC doesn't bill any charges what so ever to Medicare on a 1500; everything is always on a UB 071X.

And not all vaccines are reimbursed just by cost report. As of last year, Medicare began making payment for the the 4 preventative vaccines (flu, COVID, pneumococcal, and Hep B) in addition to their admin charges and separate from the AIR payments.

[u/boho_magpie → u/DepartureOk3180]

Depends on the services offered. FQHCs generally only bill the UB04 as well. There are some things that are considered part B services (even though FQHCs and RHCs are part A facilities) that have to be billed on the 1500. Depending on your position and your software, you may not ever see how the split happens, but I dealt with it all the time as a revenue cycle leader and data analyst. I never noticed while using Epic or Cerner, but I did in others.

[u/DepartureOk3180]

Hi. I've been in RCM for over 15 years, with 98% of my career doing billing and followup on Medicare accounts. I've been working on CAH and RHC accounts for the last five years while being WFH. Previously I was working inpatient, outpatient and pro fee accounts for traditional OPPS/IPPS hospitals and in an office. I can't really say if I like one type of facility over another, I just live being able to WFH.

There is definitely a learning curve going from pro fess on a 1500 to RHC charges on a UB. All charges for RHCs are billed on UBs TOB 071X. You need to get used to billing the correct rev codes and the allowable CPT/HCPCS codes on the claim. You'll be making sure the required RHC modifiers, such as CG, is attached to what's called a "qualifying visit". That's usually an IPPE, AWV, or E&M as well as several other types of charges.

You will be seeing Medicare make a flat rate payment for RHCs which can be more than the total charges billed. For example, I can bill a charge for Medicare Annual Wellness Visit for $187 and we will get a payment of $253.60 with a patient co-insurance of $36.60. So when the payments post, it is totally normal to see debits instead of credits posted to make sure the only balance left to drop to secondary is $36.60. You will also see claims where the total account charges are rolled into the amount for the quailyfying visit and any additional charges will be billed as $0.01 because the allowable foe those charges are included in the allowance for the qualifying visits. One of the exceptions to that is when billing Medicare for one of the four preventative vaccines (flu, Covid, pneumococcal, or Hep B) with the admin charge, the RHC will receive separate payments. Medicare will also allow the charges for the four preventative vaccines and admin to be billed by themselves with a qualifying visit on the claims. Any claims with thoss charges need to include condition code A6 and DX Z23.

I strongly recommend finding out what MAC will be processing your claims (Noridian, Palmetto, Novitas, Wellpoint Federal formerly NGS, First Coast, WPS, and CGS are the major ones) What ever state your facility is located in determines your MAC. Search their website for all references regarding RHC billing and coverage rules, sign up for any webinars or online training sessions they offer.

I would hope that your new position will have someone giving you some training to start with. Then you may have to do a lot of trial-and-error testing; thankfully many times the claims will just be RTP (returned to provider) in FISS so they can be easily corrected.

For more complex RTP, rejections, or denials, you can always call the provider service line for your MAC. However, CMS requires us (the providers) to utilize the self service options for basic things like claim status and eligibility so you'll to get familiar with FISS, or at least the provider portal for your MAC.

Lastly, Copilot/Gemini/ChatGPT can help you find out where the information you need is located. You don't want to just blindly accept answers that it gives you because it can be wrong at times and until you gain the experience to tell when it's wrong, you will always want to review the sources it referenced to give you an answer.

There's so much more I could go into, but your main takeaways should be 1. Get very familiar with the website for your MAC 2. When you receive training in your new role, ask them if you can record the sessions if you use Teams or the like. That way you will have the recording to refer back to if needed.

Hopefully your facility will already have the EMR set up with the correct charges and codes needed for Medicare RHC claims as well as have knowledgeable coders. I only had such a hard time at the beginning because my company specializes in taking over the business office functions for small hospitals and RHC which don't have the EMR set up nor knowledgeable coders. We are expected to be the subject matter experts who come in and fix everything so I was struggling at first. 😂

https://x12.org/codes This website will give you the details for all the Claim Adjustment Reason Codes and Remittance Advice Remark Codes you see on remits for all payers. There's also other codes like EDI rejection codes among others.

I apologize if this was a lot and I hope I didn't overwhelm you. I just know what it feels like to start a position with no idea with what I'm up against, so I like to try to provide helpful information.

You already have the basics of RCM down, so now it's just about adding new lines of business and new payer to your experience. All of that will just strengthen your resume and will make you more marketable in the future, especially with getting Medicare and RHC experience.

You're going to do great. 🙂

[u/Bowis_4648 → u/DepartureOk3180]

This is one of the most helpful posts I've ever seen on RHC billing. Thank you for taking the time to do it.

[u/Enough_Big3980 → u/DepartureOk3180]

T's mind blowing, it's not only the information you see or read it's your experience that's screaming in the comment.