The Fort McDermitt Wellness Center has a Purchased Referred Care (PRC) program for enrolled tribal members or those of tribal decent. This program allows the clinic to refer patients for services that are not accessible at the clinic. The funding is limited so there are guidelines that have to be followed. Patient responsibility of ensuring eligibility is the first step of those guidelines. The PRC guidelines set the standards in which services can be paid for by the program. Every Friday the PRC committee meets to determine whether referrals and payment requests meet the standards set in the PRC guidelines. Only by following these guidelines can the program continue to function. Any questions regarding PRC can be answered by the Purchase Referred Care (PRC) Coordinator at 775-532-8522 ext 128.
Patient Responsibility to be PRC Eligible
Patient responsibility is the heart of the PRC program. The whole process starts with the patient. When a patient comes into the office the first thing they must do is update any of their information with the receptionist. This includes changes to phone number, address, or insurance information. All of this plays a big part in the PRC process. If a patient’s information is not correct it makes it extremely difficult to contact the patient. Sometimes this prolongs the process of an appointment being scheduled for referrals. Also, having updated insurance helps to connect patients to outside care. Some facilities will not see patients if they do not have a primary insurance. Although some patients may find it annoying, it is a very important first step in the PRC process.
The second thing required of a patient is to apply for medical insurance if they are not already enrolled. Medicaid and Medicare are the leading insurances available to patients. The biggest issue that affects most patients is that they do not qualify for either of these and/or they cannot afford medical insurance offered through their workplace. The Fort McDermitt Wellness Center has recognized this issue and has come up with a solution. The FMWC now offers Sponsored Tribal Insurance to the tribal members of the Ft. McDermitt Paiute-Shoshone Tribe. The FMWC covers the premiums for the tribal member and their family members. For further information please reach out to Patient Benefits Coordinator. You can call her at 775-532-8522 ext 109. The Patient Benefits Coordinator can assist patients with applying for all insurances. Make sure to reach out to her if you need to apply for medical insurance coverage.
The third thing a patient must do is come back to the Fort McDermitt Wellness Center for follow up after receiving care from an outside facility. The PRC program will be able to document the care the patient received. This helps to assist patients with things that they may need from the outside facility. This also provides the PRC program updates as to if the patient will need continued care from the facility and the possibility of future bills.
Residing in the CHSDA is one of the Requirements
CHSDA is the abbreviation for Contract Health Service Delivery Area. A factor that is outside of a patients responsibility; but is a part of being PRC eligible; is living within the CHSDA of the Fort McDermitt Wellness Center. This area includes the following locations: Humboldt County in Nevada, (Denio, McDermitt, Orovada, Paradise Valley, and now Winnemucca). Oregon areas that are included in the CHSDA are Mallheur County (Jordan Valley, Nyssa, and Ontario). Keep in mind that just because a patient resides in the CHSDA does not automatically mean they will be covered by the PRC program. The patient still has to take the steps to ensure that they will be covered by the FMWC PRC program. Mainly by being an active patient and meeting the requirements listed in the PRC guidelines.
If the provider at the Fort McDermitt Wellness Center makes a finding that requires a referral they will initiate a consult note. Sometimes patients bring in appointments for care they have already been getting. This can be turned into a consult note for referral as well. This note is then sent to the PRC Coordinator. The PRC Coordinator then initiates a referral for the PRC meetings that occur every Friday. It is there that the referral is reviewed to see if it meets the guidelines of the PRC Program for approval.
Once a referral is completed for the consult note produced by a provider, the PRC Coordinator presents it at the Purchased Referred Care meeting held on a Friday. Once at the meeting the referral is looked at for these three things.
- Is the patient PRC eligible?
- Was the referral made by a provider at the Fort McDermitt Wellness Center?
- Is the priority level of the referral within the approved priority levels of the PRC policies?
If the referral meets these requirements it will be approved. Once the meeting is adjourned, the PRC Coordinator will then send the referral to the facility it needs to go to. Once the facility receives the referral a call will be placed to the patient for an appointment.
There are three statuses of a referral. There is approved, pending/deferred, and denied.
- Approved referrals are those that met all the guidelines and requirements set forth in the PRC policies and were approved during the weekly PRC meeting.
- Pending/deferred are those referrals that require more work before they can be approved.
- These referrals may belong to those patients who have not yet applied for an insurance and need to meet with Angela to get an insurance plan going.
- There may be missing documentation that needs to be acquired to meet all PRC policy guidelines.
- Denied referrals are those that did not meet all the guidelines and requirements set forth in the PRC policies.
- Denied referrals will have a letter sent to the patient and outside facility notifying them of the denial.
- A patient can appeal the denial with a request for reconsideration in writing within ten business days after receiving the denial letter.
- All grounds supporting the request for appeal must be in the letter.
- If the decision is still that of denial the patient will be notified by letter again, advising that the appeal can be taken to the PRC Coordinator within thirty days of receipt.
- All grounds supporting the request for appeal must be in the letter.
- If the decision by the PRC Coordinator is still that of denial the patient will be notified by letter again. The letter will advise that if the patient wishes to appeal again they may do so within thirty days of receipt.
- This time the letter of appeal will be taken to the health director with all grounds supporting the request for appeal.
Important Things to do at Your Appointment
- The first thing a patient needs to do before going to the appointment is to make sure they take their insurance cards with them.
- If the patient is a new patient they will need to fill out any new patient paperwork they are given.
- When it asks about insurance make sure to list insurances before listing Fort McDermitt Wellness Center.
- The patient needs to make the person registering them aware that any balances due after insurance should be forwarded to the Fort McDermitt Wellness Center and not IHS.
Most medical facilities confuse the FMWC with IHS and end up sending patient balances to other IHS facilities. It is important that the patient lets them know it is not IHS, but the Fort McDermitt Wellness Center. This will help to prevent the delay in payment of patient bills.
How Does PRC pay for a Patient’s Bill
The PRC program will not pay for a patient’s bill if a claim form is not received for the date of service being billed. A patient may bring in a billing statement but the Fort McDermitt Wellness Center still has to go through the process of having the claim form sent to the FMWC to be paid for. Some outside facilities will fax the claim by the next day. Other facilities will only mail the claim form. Depending on the outside facility it may take a week or more until the claim form reaches the FMWC.
Once the claim form is received a requisition is made up for it by the Accounting Specialist I and passed onto the PRC Coordinator. The PRC Coordinator will then gather all required information associated to the claim. This information is required to prove that the claim can be covered by the PRC program. The PRC Coordinator will present all requisitions with their information at the Friday PRC meeting.
- If the claim was the result of a referral from a provider at the FMWC it will be paid.
- If the claim was the result of a 72 hour notification to the FMWC it will be paid.
- If the claim was the result of a patient who did not provide a 72 hour notice to the FMWC it will be denied.
- If the claim was the result of a patient who acquired the bill without referral it will be denied.
- If the claim was the result of a patient who acquired the bill from another provider outside of the FMWC, it will be denied.
Once the meeting is adjourned all approved requisitions for claim payment will be given to Accounting Specialist I for payment preparation.
Receiving Care From an Outside Facility
If a patient is receiving care from an outside facility and wishes to have assistance on covering the medical bill from the PRC program, they must be seen at the Fort McDermitt Wellness Center. The patient will need to have a referral that came from a provider at the Fort McDermitt Wellness Center. Without a referral any patient bills will be ineligible to be paid by the PRC program. The patient must return for follow up visits to the FMWC as well. This helps the provider keep track of the patient and what they may need from the FMWC. Only those bills that resulted from a referral will be paid for by the PRC program.
Patients Billed Despite Having had a Referral
There is a big issue with patients receiving a billing statement from outside facilities despite being sent on a referral. A lot of this has to deal with the outside facility sending the claim form to IHS facilities. The Fort McDermitt Wellness Center is not an IHS facility and will not receive the claim form if it is sent to IHS facilities. When this happens the claim remains unpaid. So the facility then bills the patient. If a patient receives a bill they need to bring it to the FMWC. A copy of the bill will need to be given to the Business Office Manager or Health Director. They will work on getting the claim form directed to the FMWC for payment.
Emergency Room Visits and 72 Hour Notices
Emergency or urgent care visits are the only exception for requiring a referral. If a patient has an emergency room visit a 72 hour notice must be given to the Fort McDermitt Wellness Center. For those patients that are elderly and/or disabled, they are allowed a 30 day notice to the Fort McDermitt Wellness Center. Either the patient or a family member of the patient must call the FMWC and give notice of the ER visit. Failure to do so will result in the charges that occurred to be the responsibility of the patient. If patients are referred out for follow up care to an outside facility by the ER, they must first have a follow up visit with the FMWC provider. Only the referral from the FMWC will be honored by the PRC program.