Rural Health Clinics (RHCs) are vital to the ongoing care of the patient population in our country’s underserved rural areas.
By: Samantha Geroli, Mindy Singer and Donna Tarsa
Rural Health Clinics (RHCs) were established by the Rural Health Clinic Service Act of 1977 to address an inadequate supply of physicians serving Medicare beneficiaries in underserved rural areas. Also, to increase the utilization of nurse practitioners (NP) and physician assistants (PA) in these areas. Since this act was established, more RHCs are becoming available to Medicare members in rural areas.
There are two types of RHCS; a) Independent and b) Provider Based. An Independent RHC is a stand-alone or freestanding clinic that submits claims to a Medicare Administrative Contractor (MAC). A MAC is defined by the Centers for Medicare and Medicaid Services (CMS) as “a private health care insurer that has been awarded a geographic jurisdiction to process Medicare Part A and Part B (A/B) medical claims or Durable Medical Equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries.” The Provider Based RHC is an integral and subordinate part of a hospital inclusive of critical access hospitals (CAH), skilled nursing facilities (SNF) or home health agencies (HHA).
Who can Become an RHC Provider?
Medicare set special stipulations on who can provide services at an RHC. MACs state physicians, nurse practitioners, physician assistants, certified nurse midwives, clinical psychologists and clinical social workers (CSW or LCSW) are permitted to provide services. MACs also require the RHC to always be staffed at 50% with midlevel practitioners, defined as nurse practitioners, physician assistants, certified nurse midwives, clinical psychologists and clinical social workers. MACs also regulate that 51% of all services provided must be primary care services. If these requirements are not met, MACs can discontinue funding.
What is an RHC Encounter and Service?
An RHC encounter is defined as a medically necessary, face-to-face medical or mental health visit, or a qualified preventive health visit, with an RHC practitioner during which time one or more RHC services are rendered. RHC encounters can take place at a clinic, office, patient home, nursing home or skilled nursing facility. However, visiting nurse services to the homebound are only available in an area where CMS has certified that there is a shortage of home health agencies.
Requirements for Rural Health Clinic Billing
Not only are there regulatory and requirement differences between an RHC and a traditional clinic, but it is also true for billing. MACs provide incentives to become a rural provider that include specific rules for billing to receive these incentives. Independent RHCs submit professional services under clinic Part A number and technical services under group Part B number. Provider Based RHCs submit professional services under clinic Part A number and technical services under the hospital billing number. These are significant changes from traditional clinic billing as claims are normally submitted to Part B. Also, RHC encounters pay at an All-Inclusive Rate or AIR. Medicare pays 80 percent of the RHC AIR.
RHCs are vital to the ongoing care of the patient population in our country’s underserved rural areas. Understanding the differences in services and billing ensure the proper reimbursement is received and medical services are ongoing. For more information on RHCs, contact JTS Health Partners.
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