(a) Determination of the payment rate for RHCs and FQHCs that are authorized to bill on the basis of reasonable cost. (1) An all-inclusive rate is determined by the MAC at the beginning of the cost reporting period.
(1) An all-inclusive rate is determined by the MAC at the beginning of the cost reporting period.
(2) The rate is determined by dividing the estimated total allowable costs by estimated total visits for RHC or FQHC services.
(3) The rate determination is subject to any tests of reasonableness that may be established in accordance with this subpart.
(4) The MAC, during each reporting period, periodically reviews the rate to assure that payments approximate actual allowable costs and visits and adjusts the rate if:
(i) There is a significant change in the utilization of services;
(ii) Actual allowable costs vary materially from allowable costs; or
(iii) Other circumstances arise which warrant an adjustment.
(5) The RHC or FQHC may request the MAC to review the rate to determine whether adjustment is required.
(b) Determination of the payment rate for FQHCs billing under the prospective payment system. (1) A per diem rate is calculated by CMS by dividing total FQHC costs by total FQHC daily encounters to establish an average per diem cost.
(1) A per diem rate is calculated by CMS by dividing total FQHC costs by total FQHC daily encounters to establish an average per diem cost.
(2) The per diem rate is adjusted as follows:
(i) For geographic differences in the cost of inputs according to Sec. 405.2462(c)(1).
(ii) When the FQHC furnishes services to a new patient, as defined in Sec. 405.2462(c)(2).
(iii) When a beneficiary receives either of the following:
(A) A comprehensive initial Medicare visit (that is, an initial preventive physical examination or an initial annual wellness visit).
(B) A subsequent annual wellness visit. [79 FR 25478, May 2, 2014]