Objective To assess staff attitudes, knowledge, and current practices in billing third‐party payers for sexually transmitted disease (STD) services in public health departments/districts. Design and Sample A cross‐sectional, online survey was administered to staff at 60 urban and rural health departments/districts. Snowball sampling was used for greater representation. There were 311 staff responses from 56 agencies represented in the data analysis. Of the 311 responses, 106 were public health nurses and seven of the health directors had nursing backgrounds. Measurement The survey measured attitudes, knowledge, and current billing practices for STD services. Analysis of data was performed at both individual and agency level. Results Almost 90% reported it was acceptable to bill insurance. However, 56% felt these services should remain a “free” service in the agency. Most agencies were billing Medicaid for STD services (95%) and 70% bill private third‐party payers. Conclusions Current funding for public STD clinics is not sustainable and other viable income streams such as third‐party payer reimbursement must be utilized. Public health nurses play a pivotal role in developing policies and procedures in billing third‐party payers for STD and other clinical services. Understanding the interactions between attitudes, knowledge and practice are vital in this development.

Objective To assess leaders’ perceptions of challenges and opportunities to providing sexually transmitted disease (STD) services in public health departments. Design and Sample Semi‐structured interviews were conducted in 2017 with health directors and other designated leaders in 19 public health departments who have an STD clinic. Purposive sampling accounted for geographical differences, providing balanced representation of urban, suburban, and rural agencies in North Carolina. Measurement Audiotaped interviews were transcribed verbatim. All transcripts were independently coded, with cross comparison and agreement between researchers. Rigorous thematic and content analyses were performed. Results Perceived stigma, funding constraints, and client‐centered issues were identified as the greatest challenges to providing services. Opportunities to improve these services were offering comprehensive screening methods, quality improvement, and public health accreditation. Focused training on revenue and billing practices for staff was acknowledged as the most needed technical assistance. A “culture of free services”, perceived by clients and staff, was revealed throughout several themes. Conclusions Leaders in publicly funded STD clinics face many challenges and opportunities to providing clinical services. Health directors often serve as change agents and improving the sexual health of communities remains a priority. Results of this study will assist in crafting future policy and practice for STD clinics in the public health sector.