Provider-Based Rule (PBR)

Information Toolkit

Provided As a Courtesy By:

Abbey & Abbey, Consultants, Inc.

 

The following documents and/or Internet links provide the various documents that have addressed the whole “Provider-Based Rule” for Medicare.  This Rule has, and continues to undergo modification and significant interpretations.  Confusion continues to surround the precise interpretation of a number of situations relative to the Provider-Based Rule.

 

The following documents provide the resources to read and understand this rule.  Note that the documents need to be read in the context of their date of issuance since this is an evolving rule.  As much as possible the information provides any sort of date context within which the documents should be viewed.

 

Clicking on the hyperlinks will either provide you with the document from this web site or take you to a web site (CMS generally) from which the document can be obtained.

 

 

  1. PM A-99-24 – This Program Memorandum is a re-issue of the infamous PM A-96-7.  The latter PM was issued by HCFA relative to their concern about the proliferation of “Hospital-Based Clinics” and the criteria that should be met by these clinics.  Note:  This PM addresses exclusively the issue of Provider-Based Clinics which has now become one aspect of many other aspects relative to the Provider-Based Rule.  Note also that all of the criteria in this PM were gathered from various sources most of which have no basis in the CFR (Code of Federal Regulations).

 

  1. April 7, 2000 Federal Register PBR Entries – This document consists of the Preamble and CFR additions/changes section relating to the Provider-Based Rule.  This represents the beginning of the formalization of PBR.  Note:  This is the APC Federal Register entry.  The placement of the proposed PBR in this FR entry seemed to imply that the PBR related to outpatient situations only.  However, this is not the case!

 

  1. November 13, 2000, Federal Register PBR Entries – This document consists of the Preamble and CFR additions/changes section relating to PBR.  This is the CY2001 APC update Federal Register.

 

  1. August 24, 2001 Federal Register PBR Entries – These are the proposed changes for the Provider-Based Rule.  These are in the proposed changes for APCs for CY2002.

 

  1. November 30, 2001, Federal Register PBR Entries – This document consists of the Preamble and CFR additions/changes section relating to PBR.  This is the CY2002 APC update Federal Register.  Recall that the CY2002 update was delayed.

 

  1. May 9, 2002 Federal Register PBR Entries – This document consists of the Preamble and CFR additions/changes section relating to PBR.  This is the proposed FY2003 DRG update Federal Register.  It is interesting that the PBR proposed changes are in the DRG update Federal Register.  This is a small indicator that the Provider-Based Rule is applicable to more than just outpatient activities.

 

  1. August 1, 2002 Federal Register PBR Entries – This document consists of the Preamble and CFR additions/changes section relating to PBR.  This is the FY2003 DRG update Federal Register.

 

  1. CFR (Code of Federal Regulation) Entries

 

    1. 42 CFR 413.65 – This is the main entry for the Provider-Based Rule à Read with Care!!
    2. 42 CFR 489.24 – This entry addresses Emergency related requirements.
    3. 42 CFR 410.27 – This entry addresses Outpatient Services/Supplies
    4. 42 CFR 489.2 – This entry involves Provider Agreement Definitions as used in 42 CFR 413.65
    5. 42 CFR 412.22 – This entry addresses related Inpatient PPS information

 

Note:  All of the CFR entries can be downloaded from http://www.gpo.gov/nara/cfr/index.html  Care must be taken to ensure that you have the latest, most up-to-date entry.

 

  1. Provider-Based Application Form – The nationally accepted form is not yet available!

Provider-Based Application Form with Instructions

 

  1. Program Memorandum - PM A-03-030 à Dated April 18, 2003 – Effective Date:  October 1, 2002 – Implementation Date: May 1, 2003 – This PM finally provides the suggested format for the attestation form.

 

  1. OIG Reports – There are two OIG reports that indicate that there should be no such thing as provider-based in that there is a payment differential.  These reports are mainly in the context of Provider-Based Clinics.

 

    1. September, 1999 OIG Report – “Hospital Ownership of Physician Practices”
    2. August, 2000 OIG Report – “HCFA Management of Provider-Based Reimbursement to Hospitals”
    3. January, 2003 OIG Report – “Payment for Procedures in Outpatient Departments and Ambulatory Surgical Centers”

 

  1. For Provider-Based Status Clinics, the Medicare “Site-of-Service” Differential is of importance as is overall APC payment.  The latest RBRVS Federal Register entry is from December 31, 2002.  This is a delayed entry with the CY2003 RBRVS update being effective as of March 1, 2003.  You can download this FR entry from any of the GPO Gateways.  If you want the entire entry as a single file, click Total CY2003 RBRVS Federal Register.  If you want the similar APC update FR entry for CY2003, click Total CY2003 APC Federal Register.

 

  1. HCFA FAQ and HCFA MedLearn Information – The following documents were saved from CMS’s website prior to the fairly recent reorganization.  These documents no longer appear to be available and are provided as historical reference for educational purposes only!

 

    1. Provider-Based FAQs – Very interesting reading, although CMS’s answers sometimes raise additional questions!
    2. HCFA's MedLearn Chapter 6 on Provider-Based – Yes, this was included as part of the early APC training!

 

  1. CY2005 Provider-Based Rule Update

 

    1. CMS Proposed Changes to PBR - Yes, this appeared in the proposed DRG update for CY2006
    2. CMS Final Changes to PBR - And again, this appeared in the final rule for CY2006 DRGs

 

15.               For CY2009 – Supervisory Interpretation Clarification

 

a.    For the proposed and final updates to APCs for CY2009, CMS suddenly started discussing changes, which they claim to only be clarifications, in the interpretation of physician supervisory requirements for on-campus provided-based operations that are not actually in the hospital itself.  (Actually, the way the changes are phrased, these same supervisory requirements may also apply to in-hospital provider-based operations.)  The five key documents are provided below.  Note that Transmittal 87 was rescinded shortly after it was issued.  This transmittal should also be studied because it introduces a new concept, namely the physician-based clinic, which, apparently, CMS wanted to be distinct from the general concept of a freestanding clinic as enunciated in the Provider-Based Rule itself.  But, this transmittal has been withdrawn so that this concept is not currently in use, but it may indicate the direction in which CMS wants to take these rules.

b.    Provider-Based Pages from July 18, 2008 Federal Register – Yes, this is the proposed APC update Federal Register for CY2009

c.    Provider-Based Pages from November 18, 2008 Federal Register – Yes, this is the final APC update Federal Register for CY2009

d.    Transmittal 82 >>> Read with extreme care!  This appears to be a major change although CMS claims it is simply a clarification and not a change in policy.  (See Section 902 of the MMA 2003 that disallows CMS to retrospectively apply changes in policy.)

e.    Transmittal 87 <<< This transmittal was rescinded within weeks after issuance.

f.     Transmittal101 >>> Read with extreme care!  Key language was removed concerning presumption of physician supervision.

 

16.      Proposed for CY2010 - Provider-Based Pages from July 20, 2009 Federal Register – Includes Physician Supervision by Mid-Levels and ‘In the Hospital’ Definition

17.      Final Changes for CY2010 - Provider-Based Pages from November 20, 2009 Federal Register – Include Physician Supervision by Mid-Levels, Physician Supervision Requirement Changes and ‘In-the Hospital’ Definition

 

  1. Other Related Resources

 

    1. See RBRVS Update Federal Registers
    2. See APC Update Federal Registers
    3. See BIPA – Beneficiary Improvement & Protection Act – 2000 à Section 404
    4. See Section 2446 Provider Reimbursement Manual
    5. See Section 2004 State Operations Manual
    6. See EMTALA Law and Related Federal Register Entries – Proposed Changes May 9, 2002 with Final Changes September 9, 2003

 

  1. Articles and Related Resources
    1. Manson, L.A. and Baptist, A.J. – “Assessing the Cost-Effectiveness of Provider-Based Status” – Healthcare Financial Management, August 2002, Vol. 56, No. 8, Pages 52-58.
    2. Becker, S. – “HCFA Issues Guidance and Answers Questions Related to the Provider-Based Status of Facilities” – Health Care Law Monitor, November, 2000, Pages 11-21.
    3. Glover, R.L. – “Recent Changes to EMTALA Requirements for Provider-Based Entities” – Health Care Law Monitor, June, 2000, Pages 19-22.
    4. Ferman, J. – “Final Medicare Provider-Based Status Rule” – Healthcare Executive, July-August, 2000, Vol. 15, No. 4, Pages 54-55.
    5. Gundling, R.L. – “Criteria for Provider-Based Status Should Be Examined” – Healthcare Financial Management, December, 2000, Vol. 54, No. 12, Pages 66-67.
    6. Reynolds, M. – “HCFA’s New Restrictions on the Operation of Hospital Outpatient Facilities” – Journal of Health Law, 2000 Autumn, Vol. 33, No. 4, Pages 615-627.

 

Abbey & Abbey, Consultants, Inc.

Provides Provider-Based Rule Audits and Reviews For Hospitals & Hospital Systems

Contact Information:

Telephone – (515) 232-6420

E-Mail – Duane@AACIWeb.com

 

This site was last updated on January 9, 2010.