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

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.

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.

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.

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.