5 reimbursement strategies for rural health clinics
- As the healthcare funding landscape continues to evolve, rural health clinics need to explore new reimbursement strategies to generate revenue.
- Strategies like creating mobile rural health clinics or offering behavioral health services via telehealth can allow RHCs to serve a broader patient base than operating strictly as a fixed location clinic.
- RHC leaders should also consider whether certain specialty services make more sense as hospital outpatient procedures from a billing perspective and find out if changing physical location would allow them to serve a larger patient base while maintaining existing reimbursement rates.
- RHCs should review state Medicaid reimbursement rates to discover what potential opportunities exist in their respective state to net positive revenue gains.
If rural health clinics (RHCs) want to successfully navigate a constantly evolving reimbursement landscape, they need to be proactive and adaptable. Understanding changing payment methodologies, regulations in your state and the latest updates from CMS will help your RHC stay viable and able to continue to provide essential healthcare services to rural communities.
Here are five reimbursement strategies your RHC may want to consider:
1. Mobile rural health clinics
Mobile rural health clinics are growing in popularity as a way for RHCs to reach a larger patient base. Their flexibility gives providers the ability to bridge the gap between rural communities and healthcare services while using existing RHC certifications and rates.
Mobile rural health clinics do not have to be certified on their own — existing RHC-certified locations can add them to an existing Medicare enrollment — although they can be.
Mobile rural health clinics, when a part of an already-certified RHC, are viewed as an extension of the already-certified location. Therefore, they are not required to meet the RHC conditions of participation on their own. For example, a mobile clinic would not need to provide the four basic lab test requirements or include advanced practice providers to qualify since the already-certified RHC meets those requirements. In addition, specialty services could even be the only services provided in these locations.
A mobile RHC must operate with a consistent schedule and the location must have a current medically underserved area or a health professional shortage area designation. In addition, RHCs interested in using mobile clinics should check the specific state requirements that may be in place.
To maximize reimbursement, consider completing an analysis to determine which RHC (if more than one exists) to attach the mobile RHC enrollment. Using this strategy, clinics will want to look at the existing Medicare and Medicaid rates and patient payor populations of the service area being considered.
2. Telehealth behavior health providers
With the permanent ability for RHCs to provide distant site mental health services and receive payment from Medicare under the all-inclusive encounter rate, RHCs may want to consider implementing this service line. And until December 31, 2027, the in-person requirement for these services has been waived.
Clinics can contract with remote behavior health providers to offer telehealth visits while receiving the AIR for those services.
As of 2024, CMS recognizes two additional RHC practitioners with services paid at the AIR: Marriage and family therapists and mental health counselors.
3. Hospital outpatient department status
Changes to payments for provider-based RHCs may prompt grandfathered RHCs to analyze the services that they provide and bill as part of their certification.
RHCs may want to consider moving certain specialty services out of the RHC and bill under a hospital outpatient department methodology. Or, since productivity standards are no longer applicable to RHCs, services that are currently provided in the hospital may want to be analyzed under an RHC billing methodology.
The treatment of RHC and HOPD clinics varies drastically from state to state regarding Medicaid payment. Therefore, it is also important to understand how both of these types of entities are reimbursed in your state and analyze the payor type.
4. Change of address
CMS allows clinics with grandfathered RHC status to keep their existing rates even if they move locations. For providers, this lets RHCs be strategic about which locations may be optimal as a certified RHC with a grandfathered rate as long as the RHC meets the location requirements and RHC conditions of participation.
A hospital that has grandfathered RHC rates and other potential RHC locations may want to explore moving their existing certification to a clinic that has a higher Medicare and Medicaid population. That clinic location would receive the grandfathered rate, while the less utilized clinic could still apply for RHC status and receive the new federal capped rates.
Again, analyzing the potential reimbursement gain and including the Medicaid reimbursement effect would be critical.
Grandfathered RHCs need to be aware that they will lose their status if they expand beyond 50 beds.
5. Medicaid rate review
Reviewing the RHC Medicaid rates in your state and being aware of opportunities that may exist to increase them helps to ensure that your clinic is optimizing reimbursement.
The financial impact of RHC status will depend on factors such as your state's reimbursement rates and your clinic's payer mix. When reviewing the overall RHC reimbursement effect, you need to analyze the overall change in Medicare and Medicaid reimbursement.
A change in scope of services request may also be available in your state, which could potentially increase the RHC Medicaid rate. In some states, the addition of a service line such as mental health could trigger a change in scope and could result in a readjustment of a clinic’s RHC rate.
How Wipfli can help
Wipfli’s nationwide team is ready to help your RHC overcome its unique challenges. We can provide guidance on everything from navigating complex Medicare and Medicaid requirements to right-size services for rural environments. Start a conversation.
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