Rural Reimbursements

Elaine Redman

Only 4,177 rural health clinics (RHCs) exist in the entire U.S. A little over one hundred of those reside in Alabama. These clinics meet the Centers for Medicare and Medicaid Services (CMS) requirements that ensure the practice will locate in a rural setting among an underserved population. The designation also means that RHCs follow different procedures for filling out claims to receive Medicaid and Medicare reimbursements for treating patients.

"The big difference in billing for a rural health clinic instead of a standard practice is in knowing what to bill based on your insurance carrier," says Elaine Redman, billing supervisor at MediSYS. For standard practices, a claim would look the same whether it was sent to Medicare or Blue Cross. However, while RHCs use the same CPT codes, the bills look completely different from one carrier to the next because of bundling. And carriers define the bundles.

For instance, RHCs don't have office visits. "In rural health, office visits are considered encounters, and an encounter automatically bundles in additional services that a standard practice would code separately," Redman says. Those services can include the visit, shots, and administration of those shots. But some specifics, like labs, would still be filed separately, the same way standard clinics do. So rural billers need to know what services are bundled by each carrier.

But CMS is also stricter with rural practices by making doctors responsible for collecting the deductibles. Each year, Medicare patients must meet a deductible before their healthcare bills are covered. When the RHC sends in their claim for a patient who has not paid that deductible, Medicare not only rejects the claim, Medicare also subtracts the allowed amount from the physician's reimbursements. "If their deductible was $183, that clinic will have to collect that from the patient or their secondary insurance, if they have one," Redman says. "So it's extremely critical to get that deductible, or it's coming out of the clinic's pocket and their revenue is reduced."

For rural clinics that see children, Redman stresses contacting Blue Cross about their ALL Kids increased reimbursement program for RHCs. Administered through Alabama Public Health (APH) and provided by Blue Cross Blue Shield of Alabama (BCBSAL), ALL Kids offers low-cost, comprehensive healthcare coverage for children under age 19.

"ALL Kids is huge," Redman says. "If you're rural and you're filing to get a PMD [Preferred Medical Doctor] rate with Blue Cross, enroll in the All Kids program. The difference could mean $100 or more per claim for no additional work other than a signature and a date on an affidavit." She suggests that any physician, once they get their BCBS provider number, email BCBSAL for an All Kids affidavit for the provider to sign and return.

Both standard and rural practices that see children should also sign up for the state's Vaccines for Children Program. Run by APH, the program provides a wide range of free vaccines for children up to age 18 who are on Medicaid, uninsured, American Indian or Alaskan Native.

"This program will compensate a physician who would otherwise be providing vaccines out of the goodness of her heart," Redman says. "This could save thousands a year or even a month for a pediatric clinic."

Revenue for RHCs can also be found through the U.S. Health Resources & Services Administration programs. "They have programs that help support health professionals in high-need communities," Redman says. "We fill out the form every year so our client can get money back."

A new billing code open to rural practices last January could generate revenue while attaining specialist care and counseling for their Medicare patients without much travel. CMS authorized RHCs in qualifying areas to serve as the originating site for telehealth services. If the clinic allows the Medicare patient to connect with a practitioner via a telecommunications system in their facility, they can add that service to their claim as an originating site facility fee.

"A doctor can operate a rural clinic for good profit," Redman says. "With Medicaid, rural physicians tend get more reimbursement than at a standard clinic. I've seen it as high as $130 per visit over the same service at a non-RHC clinic. Typically the key for a rural clinic is not the Medicare money, but Medicaid."


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Rural Reimbursements; Elaine Redman; Medisys; Medicaid; rural health clinics; Me


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