Oregon Office of Rural Health

Rural Health Clinic Programs

Saint Alphonsus Clinic and Medical Center

ORH provides guidance on becoming a certified Rural Health Clinic (RHC), assistance on compliance and operations and Practice Assessments that include: market share, supply & demand, productivity, coding, staffing levels, staff satisfaction, and clinic benchmarks. ORH also supports RHCs by providing regular updates on the changing regulations at the federal and state levels. ORH offers the bi-monthly RHC newsletter, which provides clinics with the latest information on topics from Medicare and Medicaid, billing and coding to education opportunities. Register for the newsletter here.


Honoring the commitment to health care quality in our rural communities.

Please visit Oregon Rural Quality Excellence Award to learn more.

Technical Assistance and Resources

These resources should be considered general and preliminary only. Final determination of rural status will be made by the State of Oregon. Please contact Janice McDowell, RN971-673-3269 at Health Care Regulation and Quality Improvement (HCRQI) for final determination.

Does the clinic qualify as a rural site?

  1. The clinic is not in a Census Urbanized Area:
    1. Map of Census Urbanized Areas
    2. U.S. Department of Health and Human Services (HHS) Rural Health Information Hub’s Am I Rural? tool provides a custom report of rural status by address.
  2. The clinic is in a current Health Professions Shortage Area (HPSA) or a Medically Underserved Area (MUA) issued or renewed within the previous four years.

    HPSA: The age of the designation is calculated as the last day of the year 4 years from the date of the original designation, or the date the area was last designated. For example, a clinic that is located in an area that was most recently designated or updated on June 1, 2010, would be considered as meeting this location requirement through December 31, 2014. In Oregon, HPSA scores are updated every three years by the Oregon Health Authority’s Primary Care Office. To ensure your area’s HPSA score has not expired, contact the Primary Care Office | 503-373-1779.

    MUA: MUAs do not expire however if you are using an MUA for RHC purposes, and do not have a HPSA. The MUA designation must have been issued within the past four years.

    1. Compare site against maps and lists of Oregon HPSAs and MUAs
    2. Search HPSA & MUA by address

Is there a financial benefit to RHC status for the clinic?

RHCs (and FQHCs) receive special Medicare and Medicaid reimbursement rates for the care they provide. The RHC rate benefit can vary from clinic to clinic depending on the type of services that the clinic provides and the payer mix of the patient population.

Options:

  1. As an introductory resource, a basic Medicare-focused financial analysis worksheet is available in Starting a Rural Health Clinic, Appendix F.
  2. ORH can provide a list of RHC consultants to assist you with a detailed Medicare and Medicaid financial analysis of your current Fee-for-Service rates vs. current RHC rates. Please contact: Rondyann Gerst | 503-312-3907.

Does the clinic meet RHC personnel requirements?

More than 50% of the clinic’s services must be Primary Care: Family Care, Internal Medicine, OB/GYN, and Pediatrics. An RHC must:

  1. Employ a Nurse Practitioner (NP) or Physician Assistant (PA)

    RHCs may contract with NPs, PAs, Certified Nurse Midwives (CNM), Clinical Psychologists (CP), and Clinical Social Workers (CSW) when at least one NP or PA is employed by the RHC.

  2. Have an NP, PA, or CNM (employee + contract) working at the clinic at least 50 percent of the time the clinic operates.

Rural Health Clinics (RHCs) must complete a Medicare Cost Report annually. It is due five months from the date of the end of the RHC’s fiscal year.

The Medicare Cost Report

  1. Determines future reimbursement rates including reimbursement for Influenza and Pneumococcal vaccines given to Medicare patients;
  2. Determines allowable Medicare bad-debt write-off;
  3. Reconciles the RHC’s interim rate payment to the RHC’s actual cost per visit.

The Medicare Fiscal Intermediary may withhold payments for an unfiled Medicare cost report.

The Cost Report forms and process are slightly different for Independent vs. Provider-based RHCs:

  • Independent RHCs: Cost Report form and instructions (CMS-222-92)
  • Provider-based RHCs: Cost Report form and instructions (CMS-2552-10 – M schedules)

Wipfli LLP provides Medicare cost reporting services for both independent and provider-based RHCs.

For information on Medicaid in Oregon, refer to the Oregon Health Authority Division of Medical Assistance Programs Oregon Administrative Rules.

Provider Enrollment

  1. Complete the following RHC enrollment forms: OHP 3104OHA 3972OHA 3974, and OHA 3975. Available at: OHP Provider Enrollment.
  2. Include:
    • The clinic’s RHC Certification Letter, received from Oregon’s CMS Medicare Administrative Contractor Noridian.
    • An IRS letter confirming tax ID and status. This is a general requirement for all clinics to operate as a business, regardless of RHC status.
    • Clinical Laboratory Improvement Amendments (CLIA) Certificate from the Oregon Health Authority’s (OHA) Office of Clinical Laboratory Regulation.
    • Medicare Cost Report. This is the Cost Report completed for Medicare payment and rate calculation. For important details regarding the Cost Report and Oregon Medicaid, pay close attention to OAR 410-147 [0480] Cost Statement Instructions and OAR 410-147 [0500] Total Encounters for Cost Reports.
  3. Submit all of the above to the OHA Medical Assistance Program (MAP): Jennifer Smith | 503-602-1128.

RHC Rate Calculation and Increases

Initial RHC Rate Determination

The Medicare Cost Report informs the RHC rate calculation, which will set the clinic’s Medicaid RHC encounter rate. This rate is adjusted annually based on the Medicare Economic Index (MEI). The RHC will be enrolled with Oregon Medicaid on the date the PPS encounter rate is determined.

Oregon Medicaid Change in Scope

A change in the scope of RHC services may occur if the RHC has added, dropped or expanded any service that meets the definition of an RHC service. Full details at OAR 410-147 [0362]. If there is a change in scope which significantly changes the cost of services, a change of scope may be requested in order to qualify for a readjusted rate.

  1. Submit a narrative outlining the proposed qualifying events for a change in scope to the OHA-MAP: Jennifer Smith | 503-602-1128.
  2. OHA-MAP will review for qualifying events, and request information on the events and associated costs.
  3. OHA-MAP will work with the clinic to agree upon qualifying events, cost changes and a new rate.

Oregon Medicaid and Coordinated Care Organizations (CCOs)

All clinics, including RHCs, will need to contract with their CCO in order to receive Medicaid reimbursement and wrap-around payments for patients enrolled in CCO insurance plans. Contact the appropriate CCO about providing services for CCO patients.

CCO reimbursement rates cannot be less than your calculated RHC encounter rate; however, full reimbursement may require participating in the “Wrap-around” payments through OHA. Please see the RHC Coding and Billing Resources section of the ORH website for further details. Please contact OHA MAP to assure you are receiving your full reimbursement for OHP encounters: Jennifer Smith | 503-602-1128.

Medicare Billing and Reimbursement

  1. Noridian Healthcare Solutions
    Noridian acts as the Medicare Administrative Contractor (MAC) for Oregon and other Western states. They publish an RHC Medicare billing guide for Medicare related billing questions.
  2. CMS Rural Health Clinic Center
    1. Medicare Claims Processing Manual, Chapter 18 – Preventive and Screening Services
    2. Medicare RHC Benefit Policy Manual
    3. Medicare RHC Claims Processing Manual
    4. Medicare Billing guidance for Preventative Services
    5. Provider Wraparound Data Template | Note: Both the “Cover Page” and “Raw Data” tabs must be completed for submissions.
  3. Helpful Presentations
    1. Basic RHC Billing v. 2020:  Charles James, Jr. North American HMS
    2. Advanced RHC Billing and Coding v.2020 Charles James, Jr North American HMS

Medicaid/Oregon Health Plan (OHP) Billing and Reimbursement

  1. Billing Basics: Oregon Health Authority (OHA) presentation on billing information for all providers who serve Medicaid clients.
  2. FQHC-RHC Provider Guide 8/31/2015: Two page document with links to resources at the Oregon Health Authority’s Medical Assistance Programs (OHA MAP).
  3. Oregon Medicaid Professional Billing Instructions: includes RHC billing submission process to OHA MAP.
    1. For current Oregon Administrative RHC Rules refer to: OHA Health System Division: Medical Assistance Programs- Chapter 410
    2. If in doubt of which claim format to use, contact OHA MAP Provider Services | 800-336-6016 | for assistance.
  4. Oregon Medicaid Prepaid Health Plan Supplemental Payments (“Wraparound”)
    Federal rule requires OHA MAP to make supplemental payments (“wraparound payments”) to RHCs that contract with Prepaid Health Plans (PHP). The wraparound payment represents the difference, if any, between the payment received by the RHC from the PHP for treating the enrolled patient and the payment to which the RHC would be entitled if they had billed MAP directly for these encounters according to the RHC’s Prospective Payment System (PPS) encounter rate (OAR 410-147 [0460]). The OHA MAP Policy Analyst will coordinate this process with each RHC upon enrollment with Oregon Medicaid. Contact: Eric Larson, Fiscal Auditor | 503-945-5991.
  5. Oregon Medicaid and Change-in-Scope: A change in the scope of RHC services may occur if the RHC has added, dropped or expanded any service since initial certification. Please see 410-147 [0362] Change in Scope of Services for further details on Oregon Medicaid Change in Scope.

The Health Care Regulation and Quality Improvement (HCRQI) Section of the Oregon Health Authority (OHA) has an agreement with the Center for Medicare and Medicaid Services (CMS), to assist in determining whether health care facilities meet, and continue to meet, required conditions of participation. Questions about the application and survey may be directed to Janice McDowell, RN | HCRQI | 971-673-3269.

Complete and return the following forms to:

HCRQI Program | FAX: 971-673-0556

  • Health Insurance Benefit Agreement:  HCFA 1561 A (two signed originals required)
  • Request to Establish Eligibility:  HCFA 29
  • The following is also required for Provider-based RHCs:

    New applicants for Medicare funding and current providers undergoing a change of ownership are responsible for submitting an Assurance of Compliance (HHS-690) attesting that they will comply with all applicable civil rights laws enforceable by OCR (Title VI, Section 504, Title IX, the Age Discrimination Act, and Section 1557).

    As of September 1, 2016, OCR is accepting the HHS-690 only via the online Assurance of Compliance portal. Upon submission of the HHS-690, the providers will receive a notification that the document has been successfully submitted. Clinics should print out and include the confirmation as part of their application packet. The providers are responsible for notifying CMS and/or the state survey agency.

Complete the Medicare Enrollment Application

This must be completed and approved prior to scheduling a survey. The initial enrollment fee is currently $631– see PECOS online payment.

Two options:

  1. Medicare’s Provider Enrollment, Chain, and Ownership System (PECOS) may be used for faster processing time and online payment.

    Or

  2. Forms CMS-588 and CMS-855A may be downloaded and submitted to Noridian, the Oregon regional Medicare Administrative Contractor (MAC).

Once the HCRQI program office has received approval of the application CMS-855A from Noridian, a written request should be submitted to the HCRQI Program for a survey of the clinic. All forms must be complete, signed and submitted prior to scheduling the survey. Please note:  this will be an unannounced onsite survey. It is very important to carefully and adequately prepare for the RHC accreditation inspection. Failure of this inspection can substantially delay certification of the clinic for RHC status. In addition, if the clinic should fail the initial HCRQI inspection, it will be required to hire a private contractor for a follow-up certification inspection. To assure that a clinic meets certification inspection criteria, they will need to:

  1. Develop an RHC Policy and Procedure Manual (a sample manual is available in Appendix D of the Starting a Rural Health Clinic – A How-To Manual, or Provider- based clinics may use this template.
  2. Ensure clinic lab services are in place and licensed – CLIA Application

    Contact: The Oregon Laboratory Compliance Section | 503-693-4126.

    The clinic must have the ability to perform the following lab procedures onsite:

    • Chemical examination of urine by stick or tablet method or both
    • Hemoglobin or hematocrit
    • Blood sugar
    • Examination of stool specimens for occult blood
    • Pregnancy tests
    • Primary culturing for transmittal to a certified laboratory

Ensure that the clinic meets all conditions of certification that the HCRQI survey staff are directed to assess:

  1. Review CMS rules to surveyors
  2. Review the survey preparation checklist . The ORH RHC Program Manager will assist you in preparing for the survey.
  3. Conduct practice inspections:
    • ORH can arrange to perform a technical assistance site inspection of a clinic to identify areas of improvement necessary prior to the official HCRQI Program survey. Please contact Rondyann Gerst | 503-312-3907.
    • If a clinic plans to conduct practice inspections independently, a detailed survey preparation checklist, created by ORH and Wipfli, is available. The checklist details the specific items of focus needed to meet Federal RHC certification.

Alternative Vendor Certification options:  potentially faster alternative accreditation options are available for clinics that are willing/able to pay.  Two companies, American Association for Accreditation of Ambulatory Surgery Facilities, Inc. (AAASF) and The Compliance Team, are authorized by the CMS to offer certification services.

For the RHC Patient Engagement Series with Angie Charlet visit this link.

Webinars

Understanding RHC Advocacy and Policy Efforts

Jan. 24, 2024

What You Will Learn:

This session provides participants with information about current legislative and regulatory policy issues at the national level, and how RHCs can be informed and effective advocates.

Media

Presenter

Sarah Hohman - Director of government affairs for the National Association of Rural Health Clinics (NARHC).

Success in Chronic Care Management: How RHCs Can Benefit From Improving Patient Outcomes.

May 21, 2024

What You Will Learn:

The importance of care coordination for patients and practices, the latest updates on the billing code G0511 for 2024, and tips for implementing or improving your chronic care (CCM) program.

Media

Presenter

Kristen Ogden - Director of The Compliance Team

RHC National Legislative and Regulatory Policy Update

July 16, 2024

What You Will Learn:

Join the Office of Rural Health and Sarah Hohman, National Association of Rural Health Clinics, to gain valuable insights into current RHC legislative and regulatory policy issues at the national level.

Media

  • Video
  • Slides

Presenter

Sarah Hohman - NARHC Director of Government Affairs

Register here

The Office of Rural Health will host a quarterly RHC networking webinar calls. These calls will offer clinic leaders the opportunity to network with colleagues around the state on RHC topics. Leaders can dialogue on successes, barriers, and solutions to clinic issues. Email topics or questions prior to the calls and come ready to engage, offer input or ask questions. Patty Harper of inQuiseek will be the RHC content expert and moderate.

Moderator:
Patty Harper is CEO of InQuiseek, a business and health care consulting company based in Louisiana. She has over 21 years of health care experience in the areas of health care finance & reimbursement, health information management, compliance, and practice management. Patty is a frequent speaker and contributor for national, state, and regional rural health care associations. Patty currently serves on the Board of NARHC.

Oregon RHC Networking Call - June 5, 2024

Oregon RHC Networking Call - April 2, 2024

Oregon RHC Networking Call - Feb. 6, 2024

Oregon RHC Networking Call - Dec 5, 2023

Oregon RHC Networking Call - Aug 7, 2023

Oregon RHC Networking Call - June 7, 2023

Oregon RHC Networking Call - June 7, 2023

Behavioral Health: Leveraging RHCs to Expand an Essential Service

May 23, 2023

What You Will Learn:

Rural communities continue to experience deficits with access to behavioral and mental health services. With changes brought forth in the CY 2022 Physician Fee Schedule, Rural Health Clinics can now provide and receive reimbursement for distant site tele-behavioral health services. This presentation focuses on how to leverage RHCs and their new reimbursement methodology to expand behavioral health services.  

Media

Presenter

Jonathan Pantenburg is an accomplished, results-driven senior executive with nearly 20 years of progressively responsible experience advising profit, non-profit, and governmental entities through complex issues including cost reduction, acquisitions, contracts, financial analysis, and operations. Over the past six years, Jonathan has worked with entities ranging from independent practices to multi-state health care systems on how to leverage rural opportunities to improve financial and operational performance.  Prior to that, Jonathan served as chief financial officer and chief operating officer for a 21-bed non-profit critical access hospital.

Preventive Services Billing in an RHC

May 4, 2023

What You Will Learn:

This webinar will provide an overview of Medicare Preventive Services and how to report them on RHC claims properly.  We will look at the scope of preventive services and the difference between Stand-Alone Encounters and Same-Day Eligible Encounters.  Billing RHC preventive services at the same time as a clinical visit is rendered will be reviewed.  Claim examples for Annual Wellness Visits, IPPE, Well-Woman Examinations, Tobacco Cessation, and Alcohol Screening will be discussed.   

Media

Presenter

Charles James Jr.  is President and CEO of North American Healthcare Management Services, which has provided RHC, RCM, and EHR services for RHC and FQHCs since 1992.  He is the Executive Director of The Rural Advantage ACO, approved for Medicare Shared Savings Track A. The Rural Advantage is designed specifically for RHCs and FQHCs. Charles is the past president of the National Association of Rural Health Clinics, as well as the current President of the Illinois Rural Health Association. He also provides educational sessions and webinars on billing and compliance to state and private organizations across the United States.

North American currently provides comprehensive RCM, EHR Hosting, RHC/FQHC compliance, RHC/FQHC Billing, 340B Management/Audit, Provider Enrollment, and many other services to physicians, hospitals, RHCs, and FQHCs across the country.

Time is Money: Building RHC Value-Based Purchasing Models

May 1, 2023

What You Will Learn:

Effective primary care practices and networks have the unique ability to reduce the overall cost of care in rural communities through better patient engagement, education, prevention, clinic operations and a culture of improvement. The economic value of these cost savings should accrue at least in part to the providers and not exclusively to public and private payers. This presentation offers examples and action steps to design, implement and market rural primary care oriented VBP programs.

Media

Presenter

Jonathan Pantenburg is an accomplished, results-driven senior executive with nearly 20 years of progressively responsible experience advising profit, non-profit, and governmental entities through complex issues including cost reduction, acquisitions, contracts, financial analysis, and operations. Over the past six years, Jonathan has worked with entities ranging from independent practices to multi-state health care systems on how to leverage rural opportunities to improve financial and operational performance.  Prior to that, Jonathan served as chief financial officer and chief operating officer for a 21-bed non-profit critical access hospital.

RHC Billing Overview 2023

May 1, 2023

What You Will Learn:

This webinar will provide an RHC billing overview of the essential components of claim requirements and service reporting.  We will look at providers, locations, bundling incident-to-services, Non-RHC Services, patient co-insurance/deductible, and claim examples.  And specialists, multiple encounters, procedures in the clinic, and global billing periods in the RHC will also be discussed. 

Media

Presenter

Charles James Jr. is President and CEO of North American Healthcare Management Services, which has provided RHC, RCM, and EHR services for RHC and FQHCs since 1992.  He is the Executive Director of The Rural Advantage ACO, approved for Medicare Shared Savings Track A. The Rural Advantage is designed specifically for RHCs and FQHCs. Charles is the past president of the National Association of Rural Health Clinics, as well as the current President of the Illinois Rural Health Association. He also provides educational sessions and webinars on billing and compliance to state and private organizations across the United States.

North American currently provides comprehensive RCM, EHR Hosting, RHC/FQHC compliance, RHC/FQHC Billing, 340B Management/Audit, Provider Enrollment, and many other services to physicians, hospitals, RHCs, and FQHCs across the country.

Best Practice Checklist: RHC Financial & Operational Performance

Apr. 19, 2023

What You Will Learn:

Rural Health Clinics are emerging as one of the most strategically important departments for rural hospitals because they often represent a material revenue center, serve as the foundation for medical staff alignment and offer a bulwark against emerging competitors. This presentation identifies several tactics RHCs can implement to improve their financial and operational position given the new provider-based and independent RHC reimbursement methodologies.

Media

Presenter

Jonathan Pantenburg is an accomplished, results-driven senior executive with nearly 20 years of progressively responsible experience advising profit, non-profit, and governmental entities through complex issues including cost reduction, acquisitions, contracts, financial analysis, and operations. Over the past six years, Jonathan has worked with entities ranging from independent practices to multi-state healthcare systems on how to leverage rural opportunities to improve financial and operational performance.  Prior to that, Jonathan served as chief financial officer and chief operating officer for a 21-bed non-profit critical access hospital. 

RHC Certification A-Z

Apr. 5, 2023

What You Will Learn:

  • Learn the steps for RHC enrollment
  • Discover how to prepare for the certification survey
  • Understand the steps the clinic will take following survey to finalize certification as an RHC

Media

Presenters

Tressa R. Sacrey joined Health Services Associates in May 2015 and is the Director of Education and Compliance.  Mrs. Sacrey has a Bachelor’s Degree in Education and has completed courses in Business Applied Technology. Key areas of responsibility at HSA include creating policies, developing emergency plans, facilitating hazard training, researching CMS regulations, conducting on-site compliance mock surveys, and creating forms and tools to assist RHCs across the nation.

Michelle R. Kruzel holds a degree in Business Administration and holds the position with HSA as, Director - Enrollment and Certification. She enjoys learning and assisting providers to reach their goals of becoming a certified rural health clinic. Her areas of focus include Medicare and Medicaid credentialing, project lead and coordinator, initial and recertification mock surveys, and initial Rural Health Clinic certifications

Quality Care Through Follow-up

March 14, 2023

What You Will Learn:

Follow-up for patients can make or break a clinic.  This session will discuss tracking outside labs, consultative services, no-show appointments, and capturing return visits per provider recommendation. 

  1. Review the four key areas of follow-up within the clinic
  2. Discover tools the clinic can use to measure success
  3. Discuss the documentation expectations at the time of the survey

Media

Presenter

Tressa R. Sacrey joined Health Services Associates in May 2015 and is the Director of Education and Compliance.  Mrs. Sacrey has a Bachelor’s Degree in Education and has completed courses in Business Applied Technology. Key areas of responsibility at HSA include creating policies, developing emergency plans, facilitating hazard training, researching CMS regulations, conducting on-site compliance mock surveys, and creating forms and tools to assist RHCs across the nation.

Understanding Your Options: Primary Care Designation Strategies

March 7, 2023

What You Will Learn:

In an increasingly complex and competitive environment, the optimal alignment and designation of rural primary care practices remain essential. This presentation evaluates the different primary care practice designation types available to rural providers while explaining, with specific examples, how each designation can influence the financial performance of a clinic and its parent organization.

Media

Presenter

Jonathan Pantenburg is an accomplished, results-driven senior executive with nearly 20 years of progressively responsible experience advising profit, non-profit, and governmental entities through complex issues including cost reduction, acquisitions, contracts, financial analysis, and operations. Over the past six years, Jonathan has worked with entities ranging from independent practices to multi-state healthcare systems on how to leverage rural opportunities to improve financial and operational performance.  Prior to that, Jonathan served as chief financial officer and chief operating officer for a 21-bed non-profit critical access hospital.  

RHC Cost Reporting 101

Feb. 21, 2023

What You Will Learn:

  • How to gather the correct data: FTE, Visits, Expenses, Offsets
  • How the rate for the clinic is calculated
  • How to review the report

Media

Presenter

Julie Quinn is Vice President of Compliance and Cost Reporting at Health Services Associates. Julie is a CPA with over 25 years of experience in governmental compliance and cost reporting, 15 of which she spent in the Medicare Contractor arena. She holds an MBA with a concentration in Healthcare Administration. She assists RHCs with cost reporting, audit resolution, rate setting, and other cost and compliance issues.

Emergency Preparedness Webinar Series

A three-part webinar series featuring Patty Harper, CEO of inQuiseek who takes a deep dive into the Emergency Preparedness Program (EPP) for RHCs. 

Session One - Jan. 17, 2023
Emergency Preparedness (EP) Requirements for RHCs

The first of the three sessions will review the 42 CFR 491.12 Emergency Preparedness Program regulations for RHCs including how to prepare the All Hazard Risk Assessment. RHC participants will gain an understanding of the conditions for certification that relate to the EPP and how to meet the basic compliance requirements.

Media

Tools

Session Two - Jan. 18, 2023
Emergency Preparedness Tabletop Exercise

The second session will be an actual tabletop exercise related to a severe weather event. The event will be customizable to the weather-related events on each RHC's risk assessment (thunderstorm, winter weather, flooding, high tides, wind, and related loss of utilities). Each participating clinic will learn how to conduct a tabletop exercise and how to use the tabletop to train RHC staff.

Media

Tools

Session Three - Jan. 19, 2023
Emergency Preparedness After Action Reports

The last session of this series will focus on documenting an EP testing exercise or an EP activation. Participants will learn how to document the event properly and make any necessary revisions to their EP plan. This session will also recap the EPP requirements for RHCs and tie back to the previous sessions so that RHCs can come full circle on their knowledge and understanding of Emergency Preparedness.

Media

Presenter
Patty Harper is CEO of InQuiseek, a business and healthcare consulting company based in Louisiana. She has over 21 years of health care experience in the areas of healthcare finance & reimbursement, health information management, compliance and practice management. Patty is a frequent speaker and contributor for national, state and regional rural health care associations.  Patty currently serves on the Board of NARHC.