• Greater reimbursement rate from Medicare and Medicaid
• Greater reimbursement for Flu and Pneumonia Shots (Medicare)
• No reduction for NP & PA services
• Payment of Medicare bad debt

There are certain criteria that must be met to become an RHC and it is crucial to know what this includes prior to applying for certification.

Location: The clinic must be located in a in a federally designated Medically Underserved Area (MUA), 4-year current Health Professional Shortage Area (HPSA), or a in an area designated as underserved by the State’s Governor.  The clinic must be located and in a non-urbanized area as determined by the U.S. Bureau of the Census. Each RHC must have its own four walls certified. An RHC can be a stand-along building or a part of another building. The only services considered RHC billable outside of the actual physical RHC structure are nursing home visits, home visits, and at the scene of an accident. A mobile unit may be certified as an RHC.
Practitioners: The mid-level provider, NP, PA, CNM, must be providing patient care at least 50% of the operating clinic hours and there must be at least one employed mid-level and all others may be contracted, if desired. There must be a physician on staff who provides medical supervision, direction, and consultation. The physician may be contracted or a W-2 employee. All physicians and non-physician practitioners must be practicing in accordance with State law and State regulatory mechanism.

Services: The RHC must provide outpatient primary care service. There are six basic labs that are required to be provided within the clinic structure.

Other Requirements:
The clinic must be maintained consistent with State and local building, fire and safety codes. The building must be handicapped accessible.

• There must be a current and applicable policy & procedure manual.
• Drugs and samples must be stored safely, no expired drugs.
• Adequate medical records must be kept and maintained.
• The clinic must be under the direction of a Medical Director.

To maintain RHC certification, there are periodic requirements including holding a biennial committee meeting, annual Medicare/Medicaid cost report submissions, quarterly credit balance reports, final PPS rate setting with Medicaid, and annual policy & procedure manual review.

Becoming an RHC is not right for all clinics. First, you should complete a financial assessment. Second, you must be able to meet the above listed criteria. When a new client contacts HSA with RHC consideration in mind, we will complete the assessment before doing anything else. The Rural Assistance Center has a tool that is helpful.

RHC Types:
Provider-Based
Provider-based RHCs are owned and operated by an entity defined by Medicare statue as a provider. This includes a hospital, home health agency, or skilled nursing facility.

Independent or Free-Standing
Independent RHCs are standalone clinics, owned by a physician, NP, PA, or CNM, but may be owned by hospitals.

All new RHCs, regardless of their status as provider-based or free-standing, are subject to a capped reimbursement rate with Medicare.

Reimbursement: RHCs receive special reimbursement for Medicare and Medicaid services. Medicare visits are reimbursed based on allowable costs divided by allowable visits. All States must recognize the RHC program. Medicaid reimbursed visits are reimbursed using one of two methods: 1) Under the cost-based method of an alternative Prospective Payment System (PPS) or 2) Alternative payment methodology which includes two requirements. First, the clinic must agree to the methodology and second, the payment must at least equal the PPS payment.

There are several tasks to tackle in order to receive Medicare RHC Certification. HSA is very familiar with this process, each & every step of the way. Clinic location, staffing, and services must be verified; financial feasibility must be evaluated; forms must be completed and submitted to the appropriate processing agencies; a survey must be performed and passed; final approvals must be received; rates must be set; and unique RHC billing requirements must be utilized. Contact HSA for more information and for assistance with your certification.

• Chemical examinations of urine
• Hemoglobin or Hematocrit
• Blood sugar
• Examination of stool specimens for occult blood
• Pregnancy test
• Primary culturing for transmittal

Sometimes there is a delay of obtaining funding. Also, there can be a lack of understanding of the RHC program by Medicare Contractors or by the States. However, as your leader in RHC health care consulting, HSA has been successful in working with States across America to educate and inform clinics of the RHC purpose, structure, and how an RHC operates. 

When there are changes to your RHC, notification is mandatory and part of the Medicare/Medicaid Reporting Requirements. The type of changes that are made, will depend on who requires notification (State, Medicare, Medicaid, CMS, etc.). Some of the most common changes include practice location address, board members, phone number, change of ownership, and termination. Contact HSA at info@hsagroup.net or 231-924-0244 for more assistance.

Federally Qualified Health Centers (FQHC) were created by congress to allow special Medicare and Medicaid payments for Community/Migrant Health Centers thereby ensuring that grant dollars intended for the uninsured were available for that purpose. Congress also authorized the special Medicare and Medicaid payments for clinics that operate in compliance with the requirements of the FQHC program, but that do not receive grant funding under Section 330 of the Public Health Service (PHS) Act which are known as “look-alikes.” As stated in the January, 2013, MLN Fact sheet, the main purpose of the FQHC Program is to enhance the provision of primary care services in underserved urban and rural communities.

• Is receiving a grant under Section 330 of the PHS Act.
• Is receiving funding from a grant under a contract with the recipient of a grant and meets the requirements to receive a grant under Section 330 of the PHS Act.
• Is not receiving a grant under Section 330 of the PHS Act but is determined by the Secretary of the Department of Health & Human Services (HHS) to meet the requirements for receiving such a grant (i.e., qualifies as a FQHC look-alike) based on the recommendation of the Health Resources and Services Administration.
• Was treated by the Secretary of the Department of HHS for purposes of Medicare Part B as a comprehensive Federally funded health center as of January 1, 1990; or
• Is operating as an outpatient health program or facility of a tribe or tribal organization under the Indian Self-Determination Act or as an urban Indian organization receiving funds under Title V of the Indian Health Care Improvement Act as of October 1, 1991.
• FQHC Services are covered at the FQHC, the patient’s place of residence, or at the scene of an accident.
  FQHCs provide primary care services and preventive primary health services.
• FQHCs receive cost-based reimbursement and payment is made directly to the FQHC. The FQHC all-inclusive visit rate is calculated by dividing the FQHCs total allowable cost by the total number of visits for all FQHC patients. The payment methodology includes two national per-visit upper payment limits – one for the urban FQHC and one for the rural FQHC.
• Just like the RHC, FQHCs may be hospital owned or independent (owned by a not-for-profit or public entity).

• Primary care for all life-cycle ages, emergency care, pharmacy, preventive health, preventive dental, transportation, case management, dental screening for children, and after hours care.
• There are other areas of additional criteria that must be met comparing to the RHC. See the CMS website to find out more or contact HSA for more information.

RHCs are required to provide Good Faith Estimates (GFE) in accordance with the No Surprises Act. Our friends at NARHC have provided some helpful tools and documents that relate to the “Good Faith Estimate.” Below are some resources for your use:

• Q&A document
• Slides and Recordings
• FAQs