State Spotlight: New York Wyoming County Community Health System

Developing a Plan to Transition Physician-Based Practices into Rural Health Clinics

Wyoming County Community Health System (WCCHS) is a 64-bed hospital in a rural setting in Western New York. It has a 138-bed skilled nursing facility attached to it, along with multiple successful physician practices.

Stroudwater initially began working with WCCHS on a project to transition the designation of several of the physician practices from standalone entities to hospital-based practices. But as our worth with WCCHS progressed, an opportunity unfolded for them: they could apply for the CMS Rural Health Clinic (RHC) designation for qualifying clinics within the hospital system

Project Goals

The RHC designation is a program that entitles can leverage as part of an effective primary care strategy to address market changes to help ensure the long-term viability of hospitals and other organizations in a rural healthcare setting.

The process is not without its risks and challenges, including the requirement to employ advanced practice providers, such as a nurse practitioner, physician assistant, or certified nurse midwife.

But the RHC designation can lead to significant positive financial impacts, receiving greater reimbursement as an RHC underneath the hospital, while providing primary care access in rural communities. As a rural facility, WCCHS had experienced financial setbacks and declining reimbursement rates, and they wanted to maintain the services they were providing for patients in the county.

The project goals we set with the WCCHS team were:

  • Identifying clinics that qualified for RHC certification
  • Determining the stage of each clinic in the conversion process
  • Expanding the team from a single person to representatives from clinic operations, credentialing, and billing companies
  • Training the project team in RHC billing basics
  • Determining the status of billed claims for the WCCHS clinic that has received the RHC designation

In our initial analysis, we discovered some challenges and gaps that needed to be addressed, including:

  • Only a limited number of people had a full understanding of the RHC guidelines
  • All stakeholders needed education on RHC billing rules
  • There were multiple leadership teams at physician practices that were in various stages of transition
  • Disparate EHR and billing platforms were not using a consistent fee schedule
  • Two separate teams were responsible for the physician and hospital revenue cycle functions, and certain revenue cycle management functions were outsourced to multiple entities

Educating the Team & Taking Action Together

We first developed a list of all the physician practices and determined their RHC eligibility, documenting the stage for each in the RHC designation process. We focused on educating team members about what an RHC is, how it operates and bills differently, and why this project was ultimately beneficial for the hospital.

With more education, the team was ready to jump into action and make the appropriate changes. For example, they adjusted clinic visits to reflect Qualifying Visit (QV) services, coordinated with hospital medical records systems, and established new billing rules.

In the early stages of the project, we encountered an emergency. As we developed the list of facilities, we identified one clinic that had received the RHC designation 10 months prior and had not yet billed a claim to Medicare. This was a problem because the clinic had to bill a claim within 12 months or risk losing the designation.

They had received the RHC designation before new legislation that significantly changed the Medicare reimbursement rate. If WCCS lost the RHC designation for the clinic, they would have to complete the application process again and lose the far more favorable cost-based reimbursement rate (in 2022 dropping from $262 to $113 under the new legislation).

We took immediate action and resolved the issue, successfully billing and receiving payment for the clinic’s first Medicare claim before the deadline. Once we had resolved this short-term crisis, we developed a long-term process for the remaining clinics to follow to receive the RHC designation.

Connect with a dedicated member of our Stroudwater team to begin the process of updating your RHC designation.