Federally Qualified Healthcare Center (FQHC), also known as Community Healthcare Centers (CHCs) are non-profit organizations that strive to serve the low-income or underserved population and community groups. These provide primary outpatient services and employment opportunities for the community while working to meet the health initiatives.
FQHCs receives grants from the federal government in exchange for providing healthcare services to the uninsured and underserved population. Besides taking leverage of the federal investment in local healthcare, their practices also extend the coverage of both Medicaid and Medicare.
At present, Federally Qualified Health Centers (FQHCs) play an increasingly important role in the healthcare system, including primary care and specialty care such as obstetrics/gynecology, vision, mental health, and dental. The broader range of healthcare services provided by FQHCs makes the billing and revenue cycle process challenging.
1. FQHCs can be found in different settings and forms
They can be in rural and both the well as urban areas designated as shortage areas or in an area with a medically underserved population. FQHCs include public housing primary care centers, health centers for the homeless, community health centers, migrant health centers, or facilities operated by tribal organizations. These types of FQHCs are subject to the same billing and payment rules under Medicare.
2. FQHCs bill for visits using procedures and payment codes
If you are looking at FQHC claims data, it will not take long to notice G-codes mixed in with familiar procedure codes. FQHCs bill using payment codes in the range G0466-G0470 depending on the medical or mental health visit.
Each payment code covers a bundle of services and the codes vary based on whether the patient is established or new. FQHCs must also consider billing a procedure code to indicate services provided as part of the qualifying visit. However, the CMS does not reimburse an FQHC for the procedure codes. Care must also be taken that all the services rendered on the same day must be submitted under one claim.
3. FQHCs are required to meet specific certification requirements
FQHCs must ensure an ongoing quality assurance program, along with providing comprehensive services and meeting specific health and safety requirements. In addition to this, FQHCs must serve a medically underserved community or area and offer a sliding fee scale to patients with incomes below 200 percent of the poverty level. One of the most unique FQHC certification requirements is that they must be governed by a board of directors, the majority of whom must be patients at FQHC.
FQHCs are beaten due to constantly rising patient volume and struggle to handle growing risks, considering the fact that FFS (fee-for-service) does now no longer incentivize preventive care. As a result, they spend greater money and time on treating patients at the high end of clinical complexity, which limits their availability for new patients.
Community health facilities depend heavily on grant funding. The process of applying for funding can be time-consuming and there are chances that the funding is available for a limited time only. This eventually forces healthcare facilities to invest a great deal of time and effort in looking for new grant opportunities.
FQHCs are mission-pushed to offer holistic care to underserved communities. They recognize the impact of non-clinical challenges that keep the patients away from living their healthiest lives. But FFS reimbursements hardly ever permit providers to cope with the social determinants of health (SDOH) and might restrict possibilities to coordinate with community-based services.
When it comes to Federally Qualified Healthcare Centers (FQHCs), the billing and revenue process is generally complex. It is the federal funding and regulatory status that makes the FQHCs comply with specific billing requirements. Additionally, a large number of patients are uninsured which increases the complexity of the process.
Here are several ways to ensure that the health centers receive correct payments.
Verify patient eligibility
FQHCs generally get paid by the insurance companies. Some facilities also accept Medicaid, Medicare, and third-party payers including Health Maintenance Organization (HMO), Managed Care Organization (MCO), and Preferred Provider Organizations (PPO).
Make sure that you know which party will pay your claim before generating the bill. If you fail to do so, you might have to witness increased claim rejections for uninsured patients. Thus, always consider asking your patients for insurance proof or a third-party payer ID number.
In addition to this, verify the patient’s eligibility before providing any services while ensuring that all the required referrals are in place.
Include sliding fee
FQHCs generally get a higher rate for Medicaid and Medicare patients but they must also consider charging a sliding fee from the uninsured patients. A financial assessment must be done to determine if a patient qualifies for reduced rates. Various methods are available to decide against the charges for discounted bills. However, the most convenient method is to charge an all-inclusive fee to each slide, based on the eligibility of the patient.
Additionally, the cost of every service offered by FQHC must be analyzed since it will help them offer each service at a reduced cost.
Maintain efficient records
FQHC should actively maintain proper records of the services offered to their patients. These records ensure that the care receives proper reimbursements for all the services offered. In case a patient raises a question regarding their charges or treatment, these records can help clear things up in no time.
Outsource your FQHC billing process
Outsourcing your medical billing process means increased revenue collection along with a reduced payment turnaround time. You can expect good cash flow, reduced claim denials, timely medical billing, and higher patient satisfaction.
There is no denying the fact that FQHC medical billing is no cakewalk. High-quality analytics will only be the result of a deep understanding of the process requirements and data.
Eminence RCM has a team of highly skilled regulatory and data experts who make sure that the billing is accurate and up-to-date. Our extensive experience in FQHC billing services will ensure that your medical practice runs smoothly.
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