Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

SERVICES PROVIDED BY 

CRITICAL ACCESS 

HOSPITALS IN 2011 

Stuart Wright 

Deputy Inspector General for 

Evaluation and Inspections 

December 2013 

OEI-05-12-00081 
 

EXECUTIVE SUMMARY: SERVICES PROVIDED BY CRITICAL ACCESS 

HOSPITALS IN 2011 

OEI-05-12-00081 

WHY WE DID THIS STUDY 

The Critical Access Hospital (CAH) certification was created to ensure that rural beneficiaries 

are able to access hospital services. For most services provided, Medicare reimburses CAHs at 

101 percent of their costs rather than at the rates set by the prospective payment systems or fee 

schedules. In 2011, Medicare and beneficiaries paid approximately $8.5 billion for services 

provided at CAHs. 

CAHs are required to provide broad classes of services, including inpatient and outpatient 

services, but have latitude in what specific types of services they provide. They can also 

provide optional services such as “swing bed” services, which are the equivalent of skilled 

nursing services. 

The purpose of this report is to aid policymakers and regulators as they consider the future role 

of CAHs in the delivery of hospital services. The Office of Inspector General has 

recommended that policymakers reevaluate which facilities are certified as CAHs. In addition, 

the Administration has proposed to decertify some CAHs and change how remaining CAHs are 

paid. 

HOW WE DID THIS STUDY 

We analyzed 2011 enrollment data; inpatient and outpatient claims data; and cost report data to 

determine what types of services CAHs provided and the extent to which Medicare and other 

patients utilize these services. To provide perspective, we compared services and service 

utilization at CAHs to that within acute-care hospitals, broken out by hospital size. 

WHAT WE FOUND 

In 2011, CAHs provided outpatient services and, to a lesser extent, inpatient services to 

approximately 5 percent of all Medicare beneficiaries. At CAHs, more than eight times as 

many Medicare beneficiaries visited outpatient departments as visited inpatient departments. 

Compared to beneficiaries who received care at acute-care hospitals, a slightly higher 

percentage of beneficiaries who received services at CAHs received outpatient services. The 

outpatient services provided by CAHs were from a wide array of hospital departments. 

Laboratory services were the most commonly provided outpatient service at both CAHs and 

acute-care hospitals. 

CAHs’ inpatient beds, which are limited to a maximum of 25 at each CAH, were not heavily 

utilized. In 2011, patients used approximately one of every five available CAH inpatient beds. 

When Medicare beneficiaries did receive inpatient services at CAHs, the services provided did 

not often include operating-room procedures. In addition, more CAHs used their inpatient beds 

for swing-bed services (i.e., services that beneficiaries would receive in a skilled nursing 

facility, such as nursing care and rehabilitative therapies) than did all acute-care hospitals. On 

average, CAHs used 10 percent of their available inpatient beds to provide swing-bed services, 

while acute-care hospitals used 4 percent of their available inpatient beds. 
 

TABLE OF CONTENTS 

Objectives ....................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................5 

Results..........................................................................................................8 

Medicare Beneficiaries Used CAHs Primarily for Outpatient 

Services............................................................................................8 

Patients Used Approximately One of Every Five Available CAH 

Inpatient Beds ..................................................................................9 

CAHs Reported Providing Inpatient and Outpatient Services from
 

a Wide Array of Hospital Departments ..........................................15 

Most CAHs Provided Swing-Bed Services ...................................17 

Few CAHs Had Distinct-Part Units...............................................18 

Most CAHs Received Between $1 Million and $10 Million in 

Medicare Payments for Services Provided ....................................19 

Conclusion .................................................................................................21 

Appendixes ................................................................................................22 

Appendix A: Detailed Methodology.............................................22 

Appendix B: Distribution of CAHs across All States ...................24 

Acknowledgments......................................................................................25 

Tables 

Table 1: Number of Medicare Beneficiaries Who Visited Inpatient
 

and Outpatient Departments at CAHs and Acute-Care Hospitals ...8 

Table 2: CAHs’ Most Frequently Provided Types of Outpatient 

Services............................................................................................9 

Table 3: Bed Utilization Rates at CAHs and Acute-Care 

Hospitals ........................................................................................10 

Table 4: MS-DRGs For Which CAHS Most Frequently Billed ...13 
 

Table 5: Departments in Which More Than 60 Percent of CAHs 

Provided Services...........................................................................16 

Table 6: Departments in Which Fewer Than 50 Percent of CAHs 

Provided Services...........................................................................17 

Table 7: CAHs’ Swing-Bed Utilization Rates ...............................18 

Table 8: Distinct-Part Units at CAHs ............................................18 

Table 9: Mean, Median, and Range of Medicare Payments to 

CAHs..............................................................................................20 

Charts 

Chart 1: Medicare Beneficiaries’ Utilization of Inpatient Services 

at CAHs and Acute-Care Hospitals ................................................11
 

Chart 2: Sources of Inpatient Admissions at CAHs and Acute-Care 

Hospitals ........................................................................................12 

Chart 3: Percentages of Surgical and Medical MS-DRGs For
 

Which CAHs and Acute-Care Hospitals Billed Medicare .............14 

Chart 4: CAH Patients’ Average Lengths of Stay .........................14 

Chart 5: Distribution of Medicare Payments to CAHs .................19 
 

 

 

 

OBJECTIVE 

To provide information for policymakers to consider while reassessing 

how Critical Access Hospitals (CAHs) should be certified and paid, 

including: 

a.	 the types of services provided at CAHs in 2011; 

b.	 how the types of services provided at CAHs in 2011 compared to 

the types of services provided at acute-care hospitals in 2011; and 

c.	 how much Medicare paid for services provided at CAHs in 2011. 

BACKGROUND 

The purpose of this report is to aid policymakers as they consider the 

future role of CAHs in the delivery of hospital services. The Office of 

Inspector General (OIG) has recommended that policymakers reevaluate 

which facilities are certified as CAHs. In addition, the Administration has 

proposed to decertify some CAHs and change how remaining CAHs are 

paid. 

Critical Access Hospitals 

In 1997, the Balanced Budget Act created the CAH certification to ensure 

that hospital care is accessible to beneficiaries in rural communities.1, 2 

The CAH certification replaced designations for several other types of 

rural hospitals, including the essential access community hospital, the 

rural primary care hospital, and the Montana medical assistance facilities, 

all of which had similar features.3 Hospitals that meet specific 

requirements can qualify for the CAH certification and receive favorable 

Medicare reimbursements. 

In 2011, 1,329 CAHs were located in 45 States. These CAHs were 

predominantly located in small, rural towns, with most owned by 

nonprofit organizations such as private nonprofit companies; local hospital 

1

 Balanced Budget Act (BBA) of 1997, P.L. 105-33 § 4201. The BBA amended several 

sections of the Social Security Act, including sections 1820, 1861(mm), 1814(l), and 

1834(g). 

2

 Centers for Medicare & Medicaid Services (CMS), State Operations Manual, 

Pub. No. 100-07, ch. 2, § 2254A. Accessed at http://cms.gov/Regulations-andGuidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html (chapter-specific URL: 

http://cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/ 

som107c02.pdf) on July 7, 2011. 3

 MedPAC, Report to the Congress: Medicare in Rural America, June 2001. Accessed 

at http://www.medpac.gov/documents/jun01%20entire%20report.pdf on 

September 27, 2013. 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 1 
 

 

 

 

 

 

 

 

districts or authorities; and Federal, State, and local governments. Nearly 

40 percent of these CAHs were located in seven States, including Illinois, 

Iowa, Kansas, Minnesota, Nebraska, Texas, and Wisconsin. See 

Appendix A for a map detailing the number of CAHs in each State. 

In 2011, there were approximately 49 million Medicare beneficiaries.4 

CAHs served approximately 5 percent, or 2.3 million, of these 

beneficiaries, including 2 percent who received hospital services only at 

CAHs and 3 percent who received hospital services at both CAHs and 

acute-care hospitals. Medicare and beneficiaries paid approximately 

$8.5 billion for services provided at CAHs. 

Medicare Payments to CAHs 

CMS pays CAHs under a different payment system than most acute-care 

hospitals. CAHs receive 101 percent of their “reasonable costs” for most 

services provided. 5, 6

 CMS determines these costs using information from 

CAHs’ cost reports.7 CMS pays most acute-care hospitals using inpatient 

and outpatient prospective payment systems (IPPS and OPPS), which pay 

predetermined rates for treating beneficiaries.8, 9 Inpatient services are 

paid for based on the patients’ diagnoses, while outpatient services are 

paid for based on the services provided. 

Like other Medicare beneficiaries, beneficiaries who receive services at 

CAHs are responsible for paying a deductible and coinsurance for some 

outpatient services, such as office and emergency room visits and minor 

procedures.10 Coinsurance for outpatient services provided at CAHs is 

typically equal to 20 percent of the reasonable charges.11 Medicare 

beneficiaries generally do not pay coinsurance for other outpatient 

services, such as laboratory services and certain preventive outpatient 

services.12 

4

 CMS, The Medicare and Medicaid Statistical Supplement, 2012 Edition. Accessed at 

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-andReports/MedicareMedicaidStatSupp/2012.html on August 27, 2013.
 5

 Social Security Act, §§ 1814(l) and 1834(g), 42 U.S.C. §§ 1395(l) and 1395m(g). 

6

 “Reasonable costs” are the direct and indirect costs associated with providing services 

to Medicare beneficiaries. 42 CFR § 413.9(b)(1). 

7

 Cost reports are annual reports submitted by providers to Medicare that list providers’ 

costs and charges for delivering healthcare services. 8

 Social Security Act, § 1886(d) and (g), 42 U.S.C. § 1395ww(d) and (g).
 9

 Social Security Act, § 1833, 42 U.S.C. § 1395l.
 10 Social Security Act, § 1866(a)(2)(A), 42 U.S.C. § 1395cc(a)(2)(A). 11 Ibid. 

12 Social Security Act, § 1833(a)(1), 42 U.S.C. § 1395l(a)(1).
 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 2 
 

 

 

 

 

 

Medicare Requirements for CAH Certification 

Facilities must meet the requirements set forth in the CAH Conditions of 

Participation to receive the CAH certification. Conditions of Participation 

are health-, safety-, and location-related requirements that facilities must 

meet to participate in the Medicare program as CAHs. CAH Conditions 

of Participation include being located (1) in rural areas and (2) at a certain 

distance from other hospitals or CAHs (hereinafter referred to collectively 

as the “location requirements”); having 25 or fewer beds used for inpatient 

care or “swing bed” services; and having an average length of patient stay 

that does not exceed 96 hours (hereinafter referred to as the “4-day 

requirement”).13, 14, 15 

Maintaining CAH Certification 

CAHs are subject to periodic reassessments of their compliance with the 

CAH Conditions of Participation. CMS staff report that the current 

practice is to complete these reassessments every 3 years on average. For 

CAHs to maintain their certifications, CMS or a CMS-approved Medicare 

CAH accreditation program must verify that the CAHs continue to meet 

all CAH Conditions of Participation.16 

CAH Services 

CAHs are required to provide inpatient and outpatient services but have 

latitude in the specific services they provide. These services can include 

surgical, medical, and diagnostic services.17 Surgical services include 

operating-room procedures, like appendectomies and joint replacements. 

Medical services include all treatment services other than operating-room 

procedures, like the treatment of concussions or kidney stones. Diagnostic 

services, like imaging and laboratory services, are used to diagnose 

diseases. CAHs can also provide other types of services used to facilitate 

medical, surgical, and diagnostic services, such as ambulance services. 

Beyond inpatient and outpatient services, CAHs can also provide 

swing-bed services. Swing-bed services are equivalent to services that a 

13 Social Security Act, § 1820(c)(2), 42 U.S.C. § 1395i-4(c)(2); CMS, State Operations
 

Manual, Pub. No. 100-07, ch. 2, § 2256F. Accessed online on July 7, 2011; for URL 

details, see footnote 2.
 14 42 CFR § 485.620(a). A “swing bed” is a CAH bed that is reimbursed for skilled
 

nursing services. 

15 42 CFR § 485.620(b). 

16 CMS, State Operations Manual, Pub. No. 100-07, ch. 2, §§ 2021A and 2022B. 

Accessed online on July 7, 2011; for URL details, see footnote 2.
 17 42 CFR § 485.635; CMS, State Operations Manual, Pub. No. 100-07, Appendix W.
 

Accessed at http://cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-OnlyManuals-IOMs.html (appendix-specific URL: http://cms.hhs.gov/Regulations-andGuidance/Guidance/Manuals/downloads/som107ap_w_cah.pdf) on July 7, 2011. 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 3 
 

 

 

 

 

 

 

 

 

 

 

 

 

beneficiary would receive in a skilled nursing facility, such as nursing care 

and rehabilitation therapies. 18,19 

Finally, CAHs can also provide inpatient services in “distinct-part” 

psychiatric and rehabilitation units.20 Distinct-part psychiatric and 

rehabilitation units (hereinafter referred to collectively as “distinct-part 

units”) are inpatient units that are certified separately by Medicare and are 

distinct from CAHs’ other inpatient operations.21 

CMS pays CAHs differently for services provided in distinct-part units 

than it does for services provided in other units at CAHs. Unlike CAH 

inpatient, outpatient, and swing-bed services, which Medicare reimburses 

at 101 percent of cost, Medicare reimburses services provided in 

distinct-part rehabilitation and psychiatric units at the rates set by the IPPS 

for rehabilitation facilities and psychiatric facilities, respectively.22 

Proposed CAH Changes 

Medicare payments to CAHs have come under increased scrutiny as part 

of ongoing deficit-reduction discussions. In September 2011, the 

Administration published its Plan for Economic Growth and Deficit 

Reduction. 

23 The Plan proposed reducing CAH reimbursements to 

100 percent of reasonable costs and eliminating the critical access 

certification for CAHs located fewer than 10 miles from another hospital.24 

The Administration’s proposed budget for fiscal year 2014 made the same 

recommendations and estimated the savings over 10 years to be 

$1.4 billion from reducing reimbursement from 101 percent of reasonable 

costs to 100 percent, and $690 million from eliminating the critical access 

certifications of CAHs located fewer than 10 miles from another 

hospital.25 

Related Work 

In August 2013, OIG issued a report that focused on how many CAHs 

would meet the location requirements if required to re-enroll in Medicare. 

18 42 CFR § 485.645.
 19 42 CFR § 409.20(a). 

20 42 CFR § 485.647.
 21 CMS, Medicare Claims Processing Manual, Pub. No. 100-4, ch. 3, § 30.1. Accessed 

at http://cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-ManualsIOMs.html (chapter-specific URL: http://cms.gov/Regulations-and-Guidance/Guidance/ 

Manuals/Downloads/clm104c03.pdf) on July 30, 2013. 22 42 CFR § 413.74(e); 42 CFR pt. 412, subpts. N and P.
 23 Office of Management and Budget (OMB), Living Within Our Means and Investing in
 

the Future: The President’s Plan for Economic Growth and Deficit Reduction, 

September 2011. Accessed at http://www.whitehouse.gov/sites/default/files/omb/budget/
 

fy2012/assets/jointcommitteereport.pdf on October 24, 2011.
 24 Ibid., p. 36. 25 OMB, Fiscal Year 2014 Budget of the U.S. Government, p. 196, 2013.
 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 4 
 

 

 

OIG found that 64 percent of CAHs would not have been able to do so, 

and that Medicare and beneficiaries could realize substantial savings if 

CMS de-designated some of these CAHs and recertified them as acutecare hospitals.26 OIG recommended that CMS seek legislative authority to 

assess whether existing CAHs should retain their critical access 

certifications. In addition, OIG recommended that CMS seek legislative 

authority to revise the CAH conditions of participation to include 

measures of whether CAHs serve beneficiaries who would otherwise be 

unable to reasonably access hospital services. These criteria could be used 

to further evaluate a hospital’s CAH certification in cases where the 

hospital did not meet the current requirements related to its location. CMS 

concurred with the first recommendation but did not concur with the 

second. 

Additionally, OIG is conducting a nationwide review of the coinsurance 

that Medicare beneficiaries paid for outpatient services received at CAHs. 

Finally, OIG is conducting a nationwide review of swing-bed services at 

CAHs.27 The review compares the reimbursement for swing-bed services 

at CAHs to the reimbursement for the same level of care obtained at 

skilled nursing facilities for 2005–2010. 

METHODOLOGY 

This study provides descriptive information about CAHs nationwide in 

2011. We analyzed 2011 enrollment data, inpatient and outpatient claims 

data, and cost report data. Our purpose was to determine where CAHs 

were located, who received services at CAHs, what types of entities 

owned CAHs, how much Medicare paid CAHs, and what types of 

inpatient and outpatient services CAHs provided. 

In some cases, we also compared CAHs to acute-care hospitals. When 

comparing CAHs to acute-care hospitals, we frequently categorized 

acute-care hospitals into three groupings based on their size: small (fewer 

than 100 beds), medium-sized (between 100–399 beds), and large (400 or 

more beds).28 The term “acute-care hospitals” does not include 

psychiatric, rehabilitation, long-term care, and children’s hospitals, 

because these hospitals have operations distinct from CAHs. 

26 OIG, Most Critical Access Hospitals Would Not Meet the Location Requirements If 

Required To Re-Enroll in Medicare, OEI-05-12-00080, August 2013. 27 OIG, U.S. Department of Health and Human Services Office of Inspector General
 

Work Plan: Fiscal Year 2013, Part I, p. 7. Accessed at https://oig.hhs.gov/reports-andpublications/archives/workplan/2013/Work-Plan-2013.pdf on September 23, 2013. 28 We used the American Hospital Association’s definitions of hospital size to establish
 

the three groupings. American Hospital Association, Glossary, 2012. Accessed at 

http://www.ahadataviewer.com/glossary/ on June 13, 2013. 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 5 
 

 

 

 

We did not assess CAHs’ compliance with any Conditions of 

Participation. An earlier OIG report did assess whether CAHs would meet 

some of the Conditions of Participation—specifically, the location 

requirements—in 2011.29 

Data Sources 

Certification and Survey Provider Enhanced Reports (CASPER) database. 

The CASPER database includes data generated from certification surveys 

and includes information such as provider addresses and type of 

ownership. We used the CASPER database to identify the 1,329 CAHs 

and 3,547 acute-care hospitals included in this study. We also used the 

CASPER database to determine the addresses for all CAHs. 

2011 National Claims History (NCH) inpatient and outpatient files. The 

2011 NCH inpatient and outpatient files contain the final inpatient and 

outpatient claims data submitted by hospital providers for Medicare 

reimbursement. The 2011 NCH files include data only for Medicare 

beneficiaries. Although CAHs are not paid under a prospective payment 

system, the NCH inpatient file contains the applicable Medicare severity 

diagnosis related groups (MS-DRGs) based on information submitted on 

the claim. We used the MS-DRG present on the claim in our analysis, and 

hereinafter refer to the inpatient services provided to CAH inpatients as 

“MS-DRGs.” 

Fiscal Year (FY) 2010 and 2011 hospital cost reports. Hospitals are 

required to file annual cost reports with CMS. Hospital cost reports 

contain provider information such as facility characteristics and annual 

costs, and they include data for all hospital patients. We used 

2010 hospital cost report data whenever 2011 hospital cost report data was 

not available on CMS’s Healthcare Provider Cost Reporting Information 

System.30 

29 OIG, Most Critical Access Hospitals Would Not Meet the Location Requirements If 

Required To Re-Enroll in Medicare, OEI-05-12-00080, August 2013. 30 CMS, Cost Reports, July 25, 2013. Accessed at http://www.cms.gov/ResearchStatistics-Data-and-Systems/Files-for-Order/CostReports/Cost-Reports-by-FiscalYear.html on July 30, 2013. 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 6 
 

 

Data Analysis 

Grouping acute-care hospitals by size. To classify acute-care hospitals by 

size, we used number of inpatient beds each hospital reported on its most 

recent cost report. Of the 3,547 acute-care hospitals included in this study, 

we classified 1,290 as small, 1,770 as medium-sized, and 380 as large. 

We did not classify the remaining 107 acute-care hospitals because a cost 

report was not available or the cost report did not have information about 

the number of inpatient beds. 

Services provided by CAHs and acute-care hospitals. To describe the 

types of services provided by CAHs and acute-care hospitals, we used the 

inpatient and outpatient claims data and cost report data. Appendix A 

provides a detailed description of our analysis methods, cross-referenced 

to the corresponding table or chart in our results. 

Medicare payments for CAH services. To determine the amounts that 

Medicare paid for services provided at CAHs, we used the inpatient and 

outpatient claims data. To determine the total Medicare payment for each 

service, we summed the amount paid by Medicare and the amount paid by 

the beneficiary in the form of deductible or coinsurance. We then 

summed total payments for each CAH, and determined the percentage of 

each CAH’s total Medicare payments that came from inpatient services, 

outpatient services, and swing-bed services. 

Limitations 

Our analysis that used hospital cost report data does not account for the 

entire CAH and acute-care hospital population as some of these hospitals 

are not represented in the data. There were 51 CAHs and 208 acute-care 

hospitals that did not have 2011 cost report data. We were able to 

incorporate 33 of these CAHs and 130 of these acute-care hospitals into 

our analyses by using their 2010 cost report data. However, neither 

2011 nor 2010 cost report data were available for 18 CAHs and 

78 acute-care hospitals. To identify those instances where our analyses do 

not include all CAHs or hospitals, all tables and charts include listings of 

sample sizes and data sources. 

Additionally, we analyzed cost report data as reported by hospitals to 

CMS. This data may include figures reported in error; we did not perform 

tests designed to determine the reliability of the data. 

Standards 

This study was conducted in accordance with the Quality Standards for 

Inspection and Evaluation issued by the Council of the Inspectors General 

on Integrity and Efficiency. 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 7 
 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 8 

 

 

 

 

RESULTS 

Medicare Beneficiaries Used CAHs Primarily for Outpatient 

Services 

At CAHs, more than eight times as many Medicare beneficiaries visited 

outpatient departments as visited inpatient departments. Approximately 

2.3 million beneficiaries visited CAHs in 2011. More than 99 percent of 

these beneficiaries visited outpatient departments. Conversely, 

approximately 12 percent of all beneficiaries who visited CAHs in 

2011 visited the CAHs’ inpatient departments.31 

Similarly, most Medicare beneficiaries who received services at acute-care 

hospitals visited outpatient departments. However, compared to 

beneficiaries who received services at acute-care hospitals, a higher 

percentage of beneficiaries who received services at CAHs received 

outpatient services. Table 1 describes the frequency with which 

beneficiaries visited CAH and acute-care hospital inpatient and outpatient 

departments in 2011. 

Table 1: Number of Medicare Beneficiaries Who Visited Inpatient and Outpatient 

Departments at CAHs and Acute-Care Hospitals 

Type of hospital Department visited 

Number of 

Medicare 

beneficiaries 

Percentage of 

Medicare 

beneficiaries* 

Average number of 

Medicare beneficiaries per 

CAH or acute-care 

hospital 

CAHs (n = 1,329) 

All visits 2,329,674 1,753 

Inpatient department 282,584 12% 213 

Outpatient department 2,316,675 99% 1,743 

Small hospitals 

(n = 1,290) 

All visits 4,850,351 3,760 

Inpatient department 903,862 19% 701 

Outpatient department 4,562,533 94% 3,537 

Medium-sized 

hospitals 

(n = 1,770) 

All visits 16,602,499 9,380 

Inpatient department 5,197,601 31% 2,936 

Outpatient department 14,530,420 88% 8,209 

Large hospitals 

(n = 380) 

All visits 9,673,498 25,457 

Inpatient department 2,990,587 31% 7,870 

Outpatient department 8,334,349 86% 21,932 

Source: OIG analysis of NCH outpatient claims files, 2013. 

* See footnote 31. 

31 The overlap in percentage is attributable to the fact that some beneficiaries received 

both inpatient and outpatient services. 
 

 

 

CAHs provided outpatient services that were also commonly provided by 

acute-care hospitals. The outpatient services that CAHs provided 

Medicare beneficiaries were similar to those provided by acute-care 

hospitals. Table 2 presents the types of services that CAHs provided most 

frequently to Medicare beneficiaries in 2011 and includes listings of where 

those types of services rank in frequency relative to other types of 

outpatient services provided at acute-care hospitals.32 

Table 2: CAHs’ Most Frequently Provided Types of Outpatient Services 

Type of service 

CAHs (n = 1,329) Acute-care hospitals (n = 3,547) 

Ranking Number of times service 

was provided Ranking Number of times service was provided 

Laboratory services 1 27,685,701 1 863,400,271,981 

Minor procedures 2 5,708,563 2 122,803,730,011 

Standard imaging 3 3,130,118 3 101,639,705,004 

Other services 4 2,670,140 4 95,709,588,710 

Office visits 5 1,738,412 5 53,836,968,851 

Emergency room visits 6 1,571,794 6 44,011,438,663 

Other tests 7 1,343,317 7 41,871,350,888 

Specialist services 8 883,244 10 14,233,675,446 

Advanced imaging 9 844,236 8 34,817,749,217 

Ultrasound/echography 10 484,898 9 19,440,571,950 

Source: OIG analysis of NCH outpatient claims files, 2013. 

Patients Used Approximately One of Every Five Available CAH 

Inpatient Beds 

Patients used 21 percent of CAHs’ available bed days in 2011. Available 

bed days are the total number of inpatient beds in a hospital multiplied by 

the number of days in a year. Bed utilization rates represent the 

percentage of hospital bed days occupied over a set period. 

Patients’ utilization of CAHs’ available bed days was far less than at 

acute-care hospitals. Small acute-care hospitals had the lowest average 

bed utilization rate of all acute-care hospitals. However, CAHs’ average 

bed utilization rate of 21 percent was still lower than the 37 percent 

average bed utilization rate at small acute-care hospitals. Table 3 presents 

CAHs’ and acute-care hospitals’ average number of beds, their average 

32 Because CAHs’ most frequently provided types of outpatient services closely aligned 

with those most frequently provided by acute-care hospitals, we did not divide acute-care 

hospitals into the three groupings based on hospital size. 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 9 
 

 

 

 

 

total available bed days, their average total inpatient bed days used by all 

CAH patients, and CAHs’ and acute-care hospitals’ annual average bed 

utilization rates in 2011.33 These figures include general inpatient stays 

and exclude swing-bed or distinct-part inpatient stays. 

Table 3: Bed Utilization Rates at CAHs and Acute-Care Hospitals 

Average 

number of 

beds 

Annual average 

total available 

bed days 

Annual average total 

inpatient days 

Annual average bed 

utilization rate 

(percentage of 

available bed days 

occupied) 

CAH (n = 1,311) 22 8,042 1,726 21% 

Small hospitals 

(n = 1,290) 52 18,972 7,046 37% 

Medium-sized 

hospitals (n = 1,770) 205 74,655 42,240 57% 

Large hospitals 

(n = 380) 608 214,585 139,582 65% 

Source: OIG analysis of hospital cost reports, 2013. 

Inpatient beds at CAHs were primarily used by Medicare beneficiaries. 

Medicare beneficiaries used approximately 62 percent of all inpatient bed 

days at CAHs. In addition, CAHs provided a greater percentage of their 

total inpatient bed days to Medicare beneficiaries than did acute-care 

hospitals. Chart 1 illustrates the frequency with which Medicare 

beneficiaries utilized inpatient services at CAHs and acute-care hospitals. 

This chart shows the percentage of inpatient bed days occupied by 

Medicare beneficiaries at CAHs and acute-care hospitals. 

33 We used 2010 cost report data for 33 CAHs and 130 acute-care hospitals. 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 10 
 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 11 

 

Chart 1: Medicare Beneficiaries’ Utilization of Inpatient Services at CAHs 

and Acute-Care Hospitals 

0% 

10% 

20% 

30% 

40% 

50% 

60% 

70% 

CAHs 

(n = 1,311) 

Small hospitals 

(n = 1,290) 

Medium-sized 

hospitals 

(n = 1,770) 

Large hospitals 

(n = 380) 

Percent of total 

inpatient bed days 

used by Medicare 

beneficiaries 

 Source: OIG analysis of hospital cost reports, 2013. 

Most of CAHs’ Medicare inpatient admissions were emergency or urgent 

admissions. CAHs’ inpatient admissions for Medicare beneficiaries 

primarily resulted from emergency room visits and from occasions in 

which beneficiaries needed urgent care and were admitted to the first 

available accommodation. Emergency room visits and instances where 

beneficiaries needed urgent care accounted for approximately 74 percent 

of CAHs’ inpatient admissions. Elective admissions, meaning instances in 

which Medicare beneficiaries pre-authorized their admissions, accounted 

for 26 percent of CAHs’ inpatient admissions. Other types of admissions 

accounted for less than 1 percent of CAHs’ inpatient admissions.34 

Emergency admissions at CAHs were a smaller percentage of all 

admissions than they were at acute-care hospitals. Conversely, urgent and 

elective admissions were a larger percentage of all admissions at CAHs 

than they were at acute-care hospitals. Chart 2 summarizes the sources of 

inpatient admissions for CAHs and acute-care hospitals. 

34 Research Data Assistance Center, Claim Inpatient Admission Type Code. Accessed at 

http://www.resdac.org/cms-data/variables/Claim-Inpatient-Admission-Type-Code on 

July 30, 2013. 
 

 

 

 

   

           

Chart 2: Sources of Inpatient Admissions at CAHs and Acute-Care 

Hospitals 

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

CAHs

(n = 1,329)

Small

hospitals

(n = 1,290)

Medium‐sized

hospitals

(n = 1,770)

Large

hospitals

(n = 380)

Emergency

Urgent

Elective

Other

Source: OIG analysis of NCH inpatient claims files, 2013. 

CAHs provided few surgical inpatient surgical services. The MS-DRGs 

for which CAHs most frequently billed were primarily medical rather than 

surgical. Except for joint replacements, these MS-DRGs were for the 

treatment of illnesses like pneumonia, kidney and urinary tract infections, 

and digestive disorders. Although joint replacements were CAHs’ 

eighth most frequently billed MS-DRG, only 432 CAHs (approximately 

33 percent of CAHs) provided this service to Medicare beneficiaries. 

The MS-DRGs for which CAHs most frequently billed were different 

from those most frequently billed for by acute-care hospitals. 

Table 4 presents a ranking of the MS-DRGs for which CAHs billed most 

frequently for Medicare beneficiaries in 2011 and includes listings of how 

those MS-DRGs rank in frequency relative to other MS-DRGs billed for 

by acute-care hospitals. 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 12 
 

 

 

 

Table 4: MS-DRGs For Which CAHs Most Frequently Billed 

Ranking Description of 

MS-DRG* 

CAHs (n = 1,329) Small hospitals 

(n = 1,290) 

Medium-sized 

hospitals (n = 1,770) 

Large hospitals 

(n = 380) 

Number 

that 

provided 

service 

Number 

of times 

MS-DRG 

was 

billed 

Ranking 

Number 

of times 

MS-DRG 

was 

billed 

Ranking 

Number 

of times 

MS-DRG 

was 

billed 

Ranking 

Number 

of times 

MS-DRG 

was 

billed 

1 

Simple pneumonia 

& pleurisy w/CC 

[complications or 

comorbidities] 

1,295 23,137 2 41,798 6 141,060 9 58,599 

2 

Simple pneumonia 

& pleurisy w/o 

CC/MCC [major 

complications or 

comorbidities] 

1,297 18,486 14 20,761 32 58,572 46 21,639 

3 

Kidney & urinary 

tract infections w/o 

MCC 

1,273 17,680 5 33,233 5 149,070 6 69,468 

4 

Esophagitis, 

gastroent & misc 

digest disorders 

w/o MCC 

1,269 16,183 4 33,720 3 180,511 3 90,233 

5 

Chronic obstructive 

pulmonary disease 

w/o CC/MCC 

1,247 15,279 8 26,031 20 86,997 30 30,958 

6 

Misc disorders of 

nutrition, 

metabolism, 

fluids/electrolytes 

w/o MCC 

1,285 14,949 7 26,781 13 109,593 14 51,137 

7 Heart failure & 

shock w/CC 1,233 10,729 6 31,075 4 160,787 4 83,688 

8 

Major joint 

replacement or 

reattachment of 

lower extremity w/o 

MCC 

432 10,181 1 75,216 1 313,238 1 149,502 

9 Heart failure & 

shock w/o CC/MCC 1,217 9,889 19 16,636 30 67,623 31 30,782 

10 Cellulitis w/o MCC 1,234 9,398 11 22,358 15 107,254 16 49,234

 Source: OIG analysis of NCH inpatient claims files, 2013. 

*Wording for MS-DRG descriptions is verbatim from CMS’s FY 2011 IPPS Final Rule Data Files. 

CAHs provided fewer inpatient services that included operating-room 

procedures than did acute-care hospitals. Approximately 8 percent of the 

MS-DRGs for which CAHs billed Medicare were surgical MS-DRGs. 

Comparatively, approximately 21 percent of the MS-DRGs for which 

small acute-care hospitals—the hospital size most similar to that of 

CAHs—billed Medicare were surgical MS-DRGs. Chart 3 illustrates the 

percentages of surgical, medical, and unclassified MS-DRGs for which 

CAHs and acute-care hospitals billed Medicare. 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 13 
 

 

Chart 3: Percentages of Surgical and Medical MS-DRGs For Which CAHs 

and Acute-Care Hospitals Billed Medicare 

Source: OIG analysis of NCH inpatient claims files, 2013. 

0% 

10% 

20% 

30% 

40% 

50% 

60% 

70% 

80% 

90% 

100% 

CAHs 

(n = 1,329) 

Small hospitals 

(n = 1,290) 

Medium-sized 

hospitals 

(n= 1,770) 

Large hospitals 

(n = 380) 

Unclassified MS-DRGs 

Medical MS-DRGs 

Surgical MS-DRGs 

Most CAHs had average inpatient stays of 3–4 days. Most CAHs’ annual 

average lengths of stays fell within the statutory 4-day requirement, 

although the average length of stay at a few CAHs appears to have 

exceeded 4 days. Chart 4 shows CAHs’ average lengths of stays for all 

patients in 2011. 

Chart 4: CAH Patients’ Average Lengths of Stays 

0 

100 

200 

300 

400 

500 

600 

700 

800 

900 

Less than 3 days 3-4 days Greater than 4 days 

Number of CAHs 

(n = 1,311) 

Source: OIG analysis of hospital cost reports, 2013. 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 14 
 

 

 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 15 

 

CAHs Reported Providing Outpatient and Inpatient Services 

from a Wide Array of Hospital Departments 

CAHs provided inpatient and outpatient services from a variety of 

departments to Medicare beneficiaries in 2011. More than 75 percent of 

CAHs provided services in cardiology, respiratory, and operating-room 

departments; conversely, fewer than 25 percent of CAHs provided 

services in oncology, inpatient dialysis, or behavioral health departments. 

Table 5 lists the departments from which more than 60 percent of CAHs 

provided services, and Table 6 lists the departments from which fewer 

than 50 percent of CAHs provided services.35 

35 There were no departments in which services were provided by more than 50 percent, 

but less than 60 percent, of CAHs in 2011. 
 

 

 

 

Table 5: Departments in Which More Than 60 Percent of CAHs Provided Services 

Department Number of CAHs 

(n = 1,329) Percentage of CAHs 

Pharmacy 1,326 >99% 

Radiology – diagnostic 1,319 >99% 

EKG/ECG (electrocardiogram) 1,319 >99% 

Laboratory 1,319 >99% 

Emergency room 1,319 >99% 

Specialty services 1,312 99% 

Physical therapy 1,297 98% 

CT scan 1,282 97% 

Other imaging services 1,268 95% 

Other diagnostic services 1,252 94% 

Cardiology 1,211 91% 

Pulmonary function 1,169 88% 

Respiratory services 1,162 87% 

Operating-room services 1,136 86% 

Other therapeutic services 1,096 83% 

Magnetic resonance technology (MRT) 1,080 81% 

Speech therapy - language pathology 1,023 77% 

Occupational therapy 1,011 76% 

IV therapy 978 74% 

Anesthesia 962 72% 

Preventive care services 932 70% 

Laboratory - pathology 877 66% 

Nuclear medicine 823 62% 

Source: OIG analysis of NCH inpatient and outpatient claims files, 2013. 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 16 
 

 

 

 

Table 6: Departments in Which Fewer Than 50 Percent of CAHs Provided Services 

Department 

Number of CAHs that 

provided service 

(n = 1,329) 

Percentage of CAHs 

that provided service 

EEG (electroencephalogram) 592 45% 

Intensive care 505 38% 

Gastrointestinal (GI) services 487 37% 

Radiology - therapeutic and/or chemotherapy 

administration 451 34% 

Ambulance 302 23% 

Behavioral health treatment/services 230 17% 

Ambulatory surgical care 202 15% 

Labor room/delivery 202 15% 

Coronary care 151 11% 

Audiology 121 9% 

Trauma response 120 9% 

Oncology 58 4% 

Inpatient renal dialysis 40 3% 

Extra-corporeal shock wave therapy 36 3% 

Osteopathic services 10 <1% 

Nursery 2 <1% 

Source: OIG analysis of NCH inpatient and outpatient claims files, 2013. 

Most CAHs Provided Swing-Bed Services 

In addition to inpatient and outpatient services, approximately 92 percent 

of CAHs (1,212 CAHs) provided swing-bed services to their patients in 

2011. Swing-bed services include the same types of services that 

beneficiaries would receive in a skilled nursing facility, such as nursing 

care and rehabilitative therapies. 

More CAHs provided swing-bed services than acute-care hospitals. In 

2011, 29 percent of small acute-care hospitals (368 hospitals) and 

2 percent of medium-sized acute-care hospitals (36 hospitals) provided 

this service. Hospitals with more than 100 beds (excluding beds for 

newborns and in intensive care units) are not permitted to offer swing-bed 

services. 36 

CAHs on average used proportionally more of their available bed days 

supplying swing-bed services than did acute-care hospitals. On average, 

36 42 CFR § 482.66(a)(1). 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 17 
 

 

 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 18 

 

 

CAHs used 10 percent of their total available bed days supplying 

swing-bed services, while small and medium-sized acute-care hospitals 

used approximately 4 percent of their total available bed days supplying 

those services. Table 7 lists the number of hospitals that provided 

swing-bed services, the average total swing-bed days used by all CAH 

patients, and average total swing-bed days as a percentage of average total 

available bed days for CAHs and acute care hospitals.37 

Table 7: CAHs’ Swing-Bed Utilization Rates 

Number of 

hospitals that 

provided 

swing-bed 

services 

Average total 

available bed 

days* 

Average total 

swing-bed days 

Average total 

swing-bed days as a 

percentage of average 

total available bed 

days 

CAHs (n = 1,311) 1,212 7,799 784 10% 

Small hospitals 

(n = 1,290) 368 17,138 648 4% 

Medium-sized 

hospitals (n = 1,770) 36 40,832 1,513 4% 

Source: OIG analysis of hospital cost reports, 2013. 

* This figure includes general acute-care and swing-bed inpatient days, and excludes distinct-part inpatient days. 

Few CAHs Had Distinct-Part Units 

Most CAHs did not have distinct-part units in 2011. Only 6 CAHs had 

distinct-part rehabilitation units and 60 CAHs had distinct-part psychiatric 

units in 2011. Table 8 describes the number of CAHs that had 

distinct-part units and the number of Medicare beneficiaries who received 

services in these units. 

Table 8: Distinct-Part Units at CAHs 

Number of CAHs 

that had 

distinct-part units 

Total number of 

Medicare 

beneficiaries 

Average number of 

Medicare 

beneficiaries per CAH 

CAHs 

(n = 1,329) 

Rehabilitation 

distinct-part units 6 495 83 

Psychiatric distinct-part 

units 60 6,545 109 

Source: OIG analysis of NCH inpatient claims file, 2013. 

37 Hospitals’ total swing-bed days represents the number of days annually that are 

occupied by patients receiving swing-bed services. 
 

 

Most CAHs Received Between $1 Million and $10 Million in 

Medicare Payments for Services Provided 

Medicare payments for all types of services provided at CAHs in 

2011 ranged from less than $1 million to more than $26 million. Most 

CAHs received between $1 million and $10 million in total Medicare 

payments. Chart 5 illustrates the distribution of Medicare payments to 

CAHs in 2011. 

Chart 5: Distribution of Medicare Payments to CAHs 

0 

100 

200 

300 

400 

500 

600 

700 

Less than $1 

million 

$1 million–$5 

million 

$5 million–$10 

million 

$10 million–$15 

million 

Greater than 

$15 million 

Number of CAHs 

(n = 1,329) 

Source: OIG analysis of NCH inpatient and outpatient claims files, 2013. 

In 2011, the average CAH received approximately $6.4 million in 

Medicare payments. Of Medicare payments to the average CAH, 

approximately 30 percent were for inpatient services, 51 percent were for 

outpatient services, 19 percent were for swing-bed services, and 1 percent 

was for distinct-part psychiatric and rehabilitation services. See 

Table 9 for a description of Medicare payments to CAHs in 2011. 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 19 
 

 

 

 

 

 

Table 9: Mean, Median, and Range of Medicare Payments to CAHs

 Mean Median Minimum Maximum 

CAHs 

(n = 1,329) 

Total Medicare payments $6,360,349 $5,498,080 $147,916 $26,788,129 

Medicare payments for inpatient services $2,091,719 $1,542,403 $0 $12,588,660 

Medicare payments for outpatient services $3,302,590 $2,684,886 $92,723 $14,765,124 

Medicare payments for swing-bed services $966,040 $781,938 $0 $8,093,736 

Percentage of total Medicare payments for 

inpatient services 30.3% 29.7% 0% 71.4% 

Percentage of total Medicare payments for 

outpatient services 50.6% 50.9% 11.3% 100% 

Percentage of total Medicare payments for 

swing-bed services 19.1% 17.1% 0% 83.7% 

Source: OIG analysis of NCH inpatient and outpatient claims files, 2013. 

Some CAHs receive large percentages of their Medicare payments for just 

one type of service. For example, 53 CAHs received more than 50 percent 

of their Medicare payments for swing-bed services, including 5 CAHs that 

received more than 75 percent of their Medicare payments for such 

services. Similarly, 17 CAHs received more than 80 percent of their 

Medicare payments for outpatient services, including 7 CAHs that 

received more than 95 percent of their Medicare payments for such 

services. 

Some CAHs received a low percentage of their total Medicare payments 

for inpatient services. In 2011, 54 CAHs received less than 10 percent of 

their Medicare payments for inpatient services, including 8 CAHs that 

received less than 3 percent of their Medicare payments for such services 

and 4 CAHs that did not receive any Medicare payments for inpatient 

services. 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 20 
 

CONCLUSION 

This report provides information about the services CAHs provided in 

2011 and to what extent Medicare beneficiaries and other patients used 

these services. Policymakers and regulators can use the information 

provided in this work as they consider recommended changes to CAH 

certification requirements and payments. 

In August 2013, OIG made several recommendations about how facilities 

are certified and recertified as CAHs. OIG recommended that CMS seek 

legislative authority to assess whether existing CAHs should retain their 

certifications. OIG has further recommended that CMS seek legislative 

authority to revise the CAH conditions of participation to include 

measures of whether CAHs serve beneficiaries who would otherwise be 

unable to reasonably access hospital services. CMS could use these 

measures to further evaluate a hospital’s CAH certification in cases where 

the hospital did not meet the current requirements related to its location. 

Additionally, the Administration’s 2014 budget contains proposals about 

changes in the CAH certification requirements and how much Medicare 

should reimburse CAHs for their services. The budget proposes that 

CAHs within 10 miles of another hospital lose their certification. The 

budget also proposes decreasing Medicare reimbursement from 101 to 

100 percent of costs. 

As policymakers consider OIG’s recommendations and the 

Administration’s proposals, they should consider OIGs’ previous work on 

CAHs, the current report, and future work on the topic. Previous OIG 

work examined the location of CAHs relative to other hospitals. 

Upcoming work will examine beneficiaries’ coinsurance burden when 

receiving CAH outpatient services and Medicare reimbursement for 

swing-bed services. 

Finally, additional insights into the role CAHs play in the healthcare 

system might be gained by conducting more detailed analyses of 

individual CAHs and the capacity of the healthcare systems that are in 

close proximity to CAHs. 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 21 
 

 

 

APPENDIX A 

Detailed Methodology 

Table A-1: Analyses, Sources, and Methods by Table or Chart 

Analysis Table/ 

Chart Source Method 

Number of Medicare 

beneficiaries who visited 

CAH and acute-care 

hospital inpatient and 

outpatient departments 

Table 1 

Inpatient 

and 

outpatient 

files 

We counted the number of distinct Medicare beneficiaries who 

received inpatient and outpatient services. 

CAHs’ most frequently 

provided types of 

outpatient services 

Table 2 Outpatient 

file 

We matched each Heathcare Common Procedure Coding 

System (HCPCS) code—which described the service 

provided—to its Berenson-Eggers Type of Service (BETOS) 

code, which groups HCPCS codes into readily understood 

clinical categories.38 We then calculated the frequency with 

which each BETOS code was represented in CAH outpatient 

claims. We also calculated the frequency with which CAHs’ top 

10 BETOS codes were represented in acute-care hospitals’ 

outpatient claims. 

CAHs’ and acute-care 

hospitals’ bed utilization 

rates for all patients 

Table 3 Cost reports 

From the cost reports, we retrieved the number of inpatient beds 

and the number of inpatient bed days (days that a bed was used 

to treat an inpatient) at each CAH and acute-care hospital. We 

found the average number of beds for each group of hospitals, 

and multiplied that number by 365 to calculate the annual 

average number of available bed days. We then divided the 

number of inpatient bed days by this number to get the inpatient 

utilization rate for each group. 

Medicare beneficiaries’ 

utilization of inpatient 

services at CAHs and 

acute-care hospitals 

Chart 1 Cost reports 

From the cost reports, we retrieved the number of inpatient bed 

days that were used by Medicare beneficiaries and the total 

number of inpatient bed days at each CAH and acute-care 

hospital. We then divided the number of inpatient days that 

were used by Medicare beneficiaries by the total number of 

inpatient bed days to calculate the percentage of inpatient bed 

days used by Medicare beneficiaries for each group of hospitals. 

Sources of CAHs’ and 

acute-care hospitals’ 

inpatient admissions 

Chart 2 Inpatient file We counted the number of CAH and acute-care hospital 

admissions that came from each admission source.39 

CAHs’ most frequently 

billed MS-DRGs Table 4 Inpatient file 

We counted the number of times each MS-DRG was 

represented in CAH inpatient claims. We also calculated the 

frequency with which each CAHs’ top 10 MS-DRGs were 

represented in acute-care hospital inpatient claims. 

Percentages of surgical 

and medical MS-DRGs 

for which CAHs and 

acute-care hospitals 

billed Medicare 

Chart 3 Inpatient file 

We counted the number of surgical and medical MS-DRGs at 

CAHs and acute-care hospitals by matching the MS-DRGs 

billed to CMS’s list of FY 2011 MS-DRGs, which classified 

MS-DRGs as either surgical or medical.40 

continued on next page 

38 CMS, Berenson-Eggers Type of Service (BETOS) Codes. Accessed at 

http://www.cms.gov/Medicare/Coding/HCPCSReleaseCodeSets/BETOS.html on 

August 5, 2013. 

39 Research Data Assistance Center, Claim Inpatient Admission Type Code. Accessed at 

http://www.resdac.org/cms-data/variables/Claim-Inpatient-Admission-Type-Code on 

July 30, 2013. 

40 75 Fed. Reg. 50042, 50548 (Aug. 16, 2010). 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 22 
 

 

Table A-1: Analyses, Sources, and Methods by Table or Chart, Continued 

Analysis Table/ 

Chart Source Method 

CAH patients’ average 

lengths of stay Chart 4 Cost reports 

From the cost reports, we retrieved the average length of stay for 

each CAH’s inpatients. We then grouped the CAHs based on 

their average lengths of stay and counted the number of CAHs in 

each group. 

Departments from which 

more than 60 percent of 

CAHs provided services 

Table 5 

Inpatient 

and 

outpatient 

files 

We counted the number of CAHs that provided specific revenue 

center codes on their inpatient or outpatient claims. Revenue 

center codes describe specialized units or departments in 

hospitals.41 

Departments from which 

fewer than 50 percent of 

CAHs provided services 

Table 6 

Inpatient 

and 

outpatient 

files 

We counted the number of CAHs that provided specific revenue 

center codes on their inpatient or outpatient claims. Revenue 

center codes describe specialized units or departments in 

hospitals. 

CAHs’ swing-bed 

utilization rates for all 

patients 

Table 7 Cost 

reports 

We used the cost report data to determine the number of CAHs 

and acute-care hospitals that provided swing-bed services. We 

also retrieved the number of inpatient beds, as well as the 

number of swing-bed days (the number of days each bed was 

used to provide skilled nursing services to a patient), for each 

group of hospitals. We multiplied the number of inpatient beds 

available by 365 to calculate the number of total available bed 

days for each group. We then divided the total swing-bed days 

by the total available bed days to calculate the total swing-bed 

days as a percentage of total available bed days for each group 

of hospitals. 

Distinct-part units at 

CAHs Table 8 Inpatient file 

We counted the number of CAHs that submitted claims from a 

distinct-part unit and the number of distinct Medicare 

beneficiaries who received services in those units. We then 

divided the total number of Medicare beneficiaries by the number 

of CAHs to calculate the average number of Medicare 

beneficiaries per CAH. 

Source: OIG analysis method, 2013. 

41 Research Data Assistance Center, Revenue Center Code. Accessed at 

http://www.resdac.org/sites/resdac.org/files/Revenue%20Center%20Table.txt on 

August 5, 2013. 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 23 
 

 

APPENDIX B 

Distribution of CAHs across All States 

AK

Source: OIG analysis of NCH inpatient and outpatient claims files, 2013. 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 24 
 

ACKNOWLEDGMENTS 

This report was prepared under the direction of Ann Maxwell, Regional 

Inspector General for Evaluation and Inspections in the Chicago regional 

office; Thomas Komaniecki, Deputy Regional Inspector General; and 

Laura Kordish, Deputy Regional Inspector General. 

Lisa Minich served as the team leader for this study, and Elliot Curry 

served as the lead analyst. Other Office of Evaluation and Inspections 

staff from the Chicago regional office who conducted the study include 

Brian Jordan. Central office staff who provided support include 

Clarence Arnold, Heather Barton, and Christine Moritz. 

Services Provided by Critical Access Hospitals in 2011 (OEI-05-12-00081) 25 
Office of Inspector General

http://oig.hhs.gov 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 

amended, is to protect the integrity of the Department of Health and Human Services 

(HHS) programs, as well as the health and welfare of beneficiaries served by those 

programs. This statutory mission is carried out through a nationwide network of audits, 

investigations, and inspections conducted by the following operating components: 

Office of Audit Services 

The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 

audits with its own audit resources or by overseeing audit work done by others. Audits 

examine the performance of HHS programs and/or its grantees and contractors in carrying 

out their respective responsibilities and are intended to provide independent assessments of 

HHS programs and operations. These assessments help reduce waste, abuse, and 

mismanagement and promote economy and efficiency throughout HHS. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 

HHS, Congress, and the public with timely, useful, and reliable information on significant 

issues. These evaluations focus on preventing fraud, waste, or abuse and promoting 

economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI 

reports also present practical recommendations for improving program operations. 

Office of Investigations 

The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 

of fraud and misconduct related to HHS programs, operations, and beneficiaries. With 

investigators working in all 50 States and the District of Columbia, OI utilizes its resources 

by actively coordinating with the Department of Justice and other Federal, State, and local 

law enforcement authorities. The investigative efforts of OI often lead to criminal 

convictions, administrative sanctions, and/or civil monetary penalties. 

Office of Counsel to the Inspector General 

The Office of Counsel to the Inspector General (OCIG) provides general legal services to 

OIG, rendering advice and opinions on HHS programs and operations and providing all 

legal support for OIG’s internal operations. OCIG represents OIG in all civil and 

administrative fraud and abuse cases involving HHS programs, including False Claims Act, 

program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG 

also negotiates and monitors corporate integrity agreements. OCIG renders advisory 

opinions, issues compliance program guidance, publishes fraud alerts, and provides other 

guidance to the health care industry concerning the anti-kickback statute and other OIG 

enforcement authorities.