Profile of Rural Health Clinics: Medicare Payments & Common Diagnoses

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Overview

In 1977, Public Law 95-210 created the Rural Health Clinic (RHC) Medicare and Medicaid reimbursement designation for qualified primary care practices. With over 3,900 certified sites located across the county, RHCs are an important component of the rural health care infrastructure.1 RHCs receive cost-based reimbursement for core Medicare services, subject to tests of reasonableness. For independent RHCs and provider-based RHCs that are an integrated part of hospitals with 50 beds or more, one of these tests of reasonableness is a cap or upper limit on their cost-based rate per visit; in 2009 this cap was $76.84 per visit. Provider-based RHCs of hospitals with 49 beds or less are not subject to the cap.2 Medicare reimburses 80% of the cost-based rate for RHC services, with beneficiaries responsible for deductible and 20% coinsurance (calculated using the RHC’s charges).

Using data extracted from 2009 Medicare outpatient provider claims, this Findings Brief presents a summary profile of Medicare billing and reimbursement activity for independent and provider-based RHCs. This Findings Brief is the first in a series on RHCs which draws on a large, national secondary dataset that includes data on all RHCs that bill Medicare.3 Subsequent findings briefs in this series will profile the distribution and characteristics of individual clinics as well as the characteristics of Medicare beneficiaries served by RHCs.

Key findings

  • In 2009, RHCs filed over 8.1 million claims to Medicare with total charges of $869 million, and $809 million due in reimbursement from all sources (Medicare, patient, other).
  • The majority of RHC Medicare claims are for clinic visits (89%) and another 9% are for home, skilled nursing facility (SNF) or long-term care (LTC) visits. Revenue codes for behavioral health, visiting nurse services, and telemedicine are rarely billed.
  • The most common medical conditions for Medicare beneficiaries seen by RHCs in 2009 include hypertension, diabetes mellitus, respiratory infections and diseases of the heart.

For the complete PDF, check out the paper.