36 Clinics Probed for Medicare Eligibility

Federal health care officials are reviewing Ventura County’s network of public health clinics to determine whether each meets Medicare eligibility guidelines, officials said last week.

The review is a byproduct of the county’s failed attempt last year to merge its mental health and social service departments. The Board of Supervisors rescinded its vote in December after federal officials said the new structure violated Medicare billing rules.

A federal audit of health care billings for the eight months the agencies were combined is underway.

And officials confirmed Friday that the U.S. Health Care Financing Administration is also reviewing 36 health clinics affiliated with the Ventura County Medical Center.

At issue is whether the hospital’s outpatient facilities are eligible for Medicare reimbursements under requirements revised three years ago, said Helen Gookin, an HCFA health insurance specialist. Once approved for Medicare, the clinics are also eligible to receive Medi-Cal funding, she said.

HCFA is requesting that the county fill out a questionnaire describing the location and administrative structure of each clinic. Officials want to make sure the medical center has administrative authority over the clinics and that the facilities are not located too far from the hospital, Gookin said.

“They have to meet specific requirements, and the questionnaires give us the information to make that judgment,” she said. “Once we look at them, we will know whether or not they are approved.”

County Counsel James McBride said the county is being assisted in its response by an outside legal firm and a consulting group that specializes in federal health care billings.

McBride said the county believes all of the clinics are in compliance with billing rules, although minor changes may be necessary.

“There may need to be a little tweaking,” McBride said. “These reviews go on all the time, and if you are out of compliance, you tweak it a little.”

Health Care Agency Director Pierre Durand said recently that his staff was compiling documentation that will be forwarded to federal officials soon. Durand did not return calls last week seeking further comment.

McBride said federal guidelines indicate that even if a clinic is found out of compliance, the county will not be held liable for health dollars received if the problem is fixed. The county receives millions of dollars in Medicare and Medi-Cal revenue from the clinics each year, McBride said.

Gookin, however, said it is too early to say what penalties, if any, HCFA might impose.

“That would be determined later,” she said.

Ventura County’s public hospital, located in Ventura, has long operated off-site clinics, administrator Bill Wood said. In the early 1980s, Dr. Joan Baumer tended to sick patients out of a trailer on Ventura Avenue at the city’s western fringe, he said.

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In the mid-1980s, Durand began building a network of clinics to give poor neighborhoods greater access to medical care. Today, the clinics log 300,000 visits a year, Wood said. About 68% of the patients are covered by Medi-Cal or Medicare, health insurance programs for the poor and elderly, respectively.

Twelve of the clinics offer specialized services, such as pregnancy care, children’s health and cardiology, Wood said. Those clinics are inside the Ventura County Medical Center at 3291 Loma Vista Road or are nearby, he said.

Another 10 are off-site clinics that offer general medical care, and 14 are off-site mental health facilities, Wood said. They are spread across the county, from Ventura to Simi Valley, as outpatient units of the hospital, he said.

One area being questioned is whether the hospital is truly in charge of running the clinics, Gookin said. Ventura, like other counties, contracts with private physicians to provide services at some clinics. The hospital must show it has daily oversight of the facilities, including authority over personnel decisions, Gookin said.

Off-site clinics should also be within “close proximity” of the medical center, according to a Medicare policy memorandum. HCFA doesn’t have a specific mile limit, Gookin said, but “it has to be close enough that we can believe the hospital has daily oversight” of the facility.

Sierra Vista Family Care in Simi Valley is more than 40 miles from Ventura County Medical Center; other medical and mental health clinics are in Piru, Moorpark and Thousand Oaks.

McBride said the county owns each of the clinic sites and the equipment used in them. He said he did not know whether county officials are concerned about the distance between outlying clinics and the medical center.

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Medicare tightened its rules for outlying clinics in 1996, Gookin said. Federal officials became concerned because some hospitals were generating higher Medicare payments by designating clinics as “outpatient” departments.

If any of Ventura County’s clinics are not eligible under new guidelines, the county can convert them to free-standing clinics, she said. Clinic administrators would then bill Medicare at a lower rate, Gookin said.