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Rural Oral and Maxillofacial Surgeon Case Mix Leads to Lower Medicare Reimbursement

Rural Oral and Maxillofacial Surgeon Case Mix Leads to Lower Medicare Reimbursement



Rural Oral and Maxillofacial Surgeon Case Mix Leads to Lower Medicare Reimbursement




Journal of Oral and Maxillofacial Surgery, 2020-11-01, Volume 78, Issue 11, Pages 2009.e1-2009.e7, Copyright © 2020 American Association of Oral and Maxillofacial Surgeons


Purpose

A relative paucity of literature exists analyzing rural-urban differences in Medicare insurance claims by oral and maxillofacial surgeons (OMSs). The purpose of this study is to compare Medicare utilization, billing practices, and reimbursement rates between rural OMSs and their urban counterparts.

Methods

This cross-sectional study examines Medicare claims data from the 2017 Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File. The primary predictor variable was the provider Rural-Urban Commuting Area Code (rural vs urban). The primary outcome variable was the total Medicare standardized payment amount per OMS. Additional variables include total number of services provided, total unique Healthcare Common Procedure Coding System codes submitted, total submitted charge amount for all services, mean beneficiary hierarchical condition category, and the total Medicare allowed/payment amount for all services. Descriptive statistics were calculated and continuous variables were compared using nonparametric Mann-Whitney U tests.

Results

The analysis cohort had 921 OMSs who recorded 114,169 Part B services in 2017. Urban OMSs billed more services compared to rural OMSs, saw patients with a higher average hierarchical condition category score, and submitted more claims per beneficiary. The mean reimbursement-to-charge ratio was higher among rural OMSs, although the mean payment per service was higher among urban surgeons.

Conclusions

Rural OMSs bill fewer unique codes and treat less medically complex patients compared with their urban counterparts. Rural surgeons were reimbursed proportionally higher for their total submitted charges than urban surgeons; however, they were reimbursed less for each individual service provided. These differences may be attributable to the Centers for Medicare & Medicaid Services Multiple Procedure Payment Reduction policy and provider case mix.


Introduction

Medicare participation and utilization within the field of oral and maxillofacial surgery has only recently been subject to evaluation; however, to date, there is no literature analyzing rural-urban differences in Medicare claims for oral and maxillofacial surgery services. Recent work demonstrated inequitable access to oral and maxillofacial surgery services in the Medicare population, with some states having no oral-maxillofacial surgeons (OMSs) accepting Medicare. Subsequent studies have shown differences in Medicare reimbursement rates among OMSs, varying by sex, type of practice, and scope of procedures. , The purpose of this study is to characterize differences in Medicare insurance claims for oral and maxillofacial services in rural counties relative to their urban counterparts. The specific aims of this study are to 1) assess differences in Medicare billing practices by OMSs for services provided in rural and urban counties in the United States (US) and 2) compare Medicare reimbursement rates between rural and urban OMSs. We hypothesize that OMSs in rural counties bill fewer services relative to urban OMSs.


Methods


Study Design and Population

This cross-sectional study analyzed the 2017 Medicare Provider Utilization and Payment Data: Physician and Other Supplier Public Use File and associated Aggregate Provider Summary Table. These data contain all Part B claims for the Medicare fee-for-service population from 2017, aggregated by the provider, for physicians who saw more than 10 Medicare patients per calendar year. To be included in the study, providers must be labeled with the provider type “maxillofacial surgery,” confirmed with National Provider Identifier number, and have a listed Rural-Urban Commuting Area Code (RUCA). As all data were publicly available and anonymous, institutional board review was not required.


Study Variables

The primary predictor variable was the provider RUCA (rural vs urban) based on county. RUCAs, available starting in 2017, are a US Census tract-based classification scheme that use measures of population density, urbanization, and daily commuting to characterize US county rural-urban status. Providers with listed RUCA codes 1-3 were assigned urban status, and providers with listed RUCA codes 4-10 were assigned rural status.

The primary outcome variable was the total Medicare standardized payment amount per OMS. The standardized payment amount adjusts for geographical differences in payment rates for individual services, allowing multistate comparison of Medicare payments. Secondary outcome variables included total number of services provided per OMS, total unique Healthcare Common Procedure Coding System (HCPCS) codes submitted per OMS, total submitted charge amount for all services per OMS, total Medicare allowed amount for all services per OMS, total Medicare payment amount for all services per OMS, and the mean beneficiary hierarchical condition category, a Medicare risk adjustment model designed to communicate patient complexity. Additional variables included provider gender (male or female) and Medicare beneficiary age.


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