Exception-al CRNAs: Sometimes the Sole Provider in Rural Areas

According to the American Association of Nurse Anesthetists, nurse anesthetists are the oldest nurse specialty group in the United States and have been providing anesthesia care to patients in the United States for more than 150 years. The CRNA (Certified Registered Nurse Anesthetist) credential came into existence in 1956.

CRNAs are the primary providers of anesthesia care in rural America, enabling health care facilities in these medically underserved areas to offer obstetrical, surgical, pain management and trauma stabilization services. In some states, CRNAs are the sole providers in nearly 100 percent of the rural hospitals.[1]

The services of a non-physician anesthetist (CRNA) generally are paid for by the Part B contractor based on a fee schedule rather than on reasonable cost basis through the cost report.

But for some qualified rural hospitals or Critical Access Hospitals, a request can be made on an annual basis for an exception if the facility employed or contracted with not more than one FTE (2080 hours) non-physician anesthetist. There is also a threshold of 800 or fewer surgical procedures requiring anesthesia services and there can be no professional fee billing for the CRNA.

Tip #33:

Rural and Critical Access hospitals can request an exception to the CRNA Fee schedule if they meet certain criteria (CMS Pub 15-2, Section 4013). Further guidance can be found on the Centers for Medicare and Medicaid Services (CMS) website:

Provider Reimbursement Manual 15-2, Chapter 40

Questions? Please contact Marie White at 612.253.6546 or mewhite@eidebailly.com.

[1] American Association of Nurse Anesthetists, “Certified Registered Nurse Anesthetists Fact Sheet.”

The Effect of Shrinking Rural America on Medicare Productivity Standards

michael-smithIn 1900, some 40 percent of the population worked in agriculture, a century later, only two percent did.1 Manufacturing jobs in most small towns began to disappear by the 1980s. Rural America, more than much of the rest of the country, is the victim of productivity gains. And in rural America, fewer other opportunities materialize to replace the jobs the machines take.

Our transition from rural to metropolitan has been rapid. At the beginning of this century, 60 percent of the people lived on farms or in villages. Today, just 19 percent of Americans live in areas the Census department classifies as rural, down from 44 percent in 1930.

This week’s tip goes hand-in-hand with our previous posting (please see tip #22) on the importance of accurately calculating your physician and mid-level FTEs for Rural Health Clinics (RHCs). The RHCs could receive enhanced reimbursement from Medicare and Medicaid, but this is dependent upon FTE counts and the relationship to productivity thresholds.

In some situations, a RHC has the necessary physician or mid-level to provide care, but due to declining populations, economic conditions or a combination of these, insufficient patient volumes exist to prevent the RHC from being impacted by the thresholds.

Tip #28:

The Medicare Administrative Contractor that processes Part A and Medicare Part B claims has the discretion to make an exception to the productivity standards based on individual circumstances (Chapter 13, Section 80.4).

Further guidance can be found on the Centers for Medicare and Medicaid Services (CMS) website:

Medicare Benefit Policy Manual RHC/FQHC

Questions? Please contact Michael Smith at 701.239.8635 or msmith@eidebailly.com.

1“The Graying of Rural America,” by Alana Semuels, The Atlantic

Miles per Dollar and RHC FTEs

People running Outdoor activity Healthy lifestyleWhat if someone offered you $10,000 to walk 10 miles; the next person is offered $10,000 and only has to walk five miles? Then another person is offered $10,000 for one mile. Your 10-mile deal seems pretty unfair now, doesn’t it? Why should someone walk less and get paid the same? Productivity standards in health care exist to prevent this type of unfairness. A minimum level of effort is established to correspond with the dollars to be paid.

The Rural Health Clinic (RHC) program is intended to increase access to primary care services for Medicaid and Medicare patients in rural communities. A RHC is a clinic located in a rural, medically under-served area in the United States as defined by the Health Resources and Services Administration.

RHCs are staffed by a combination of physicians, nurse practitioners (NP), physician assistants (PA), and certified nurse midwives (CNM). Minimum staffing levels are required based on full-time equivalents or FTEs (which are the “miles”).

The computation of the FTE for each nurse practitioner, physician assistant, or certified nurse midwife can be confusing as only the time spent seeing patients or scheduled to see patients should be counted. The same challenge exists in computing the Physician FTE.

Tip #22:
Ensure RHC FTEs are properly computed (Chapter 13, §80.4).

Further guidance can be found on the Centers for Medicare and Medicaid Services (CMS) website:

Medicare Benefit Policy Manual RHC/FQHC

Questions? Please contact Marie White at 612.253.6546 or mewhite@eidebailly.com.