Learn How to Avoid FQHC Billing Roadblocks

Overcome billing challenges with processes that pave the way to a healthy revenue cycle.

Federally qualified healthcare centers (FQHCs) are taking on a more prominent role in our healthcare system, providing primary care, as well as multi-specialty services including obstetrics/gynecology (OB-GYN), mental health, vision, and dental services. Because of the wide array of services provided in FQHCs, it may be a challenge to navigate the billing and revenue cycle process. We’ll review some tips to help you understand and overcome those challenges.

FQHC Requirements

FQHCs have become integral to providing healthcare to low-income, uninsured populations; but with Medicaid expansion and the skyrocketing cost of commercial healthcare, many FQHCs are serving all kinds of patients, not just those with low income. If you’re unfamiliar with how FQHCs operate, here are some basic facts:

  • FQHCs must offer services to all (regardless of a person’s ability to pay); establish a sliding fee program for discounts; and prove they are in a medically underserved area. There are reporting requirements and quality standards that must be met to keep designation and funding.
  • FQHCs are reimbursed at a flat prospective payment system rate for each face-to-face visit with Medicare and Medicaid eligible patients, which is a much higher rate as compared to non-FQHC practices and physicians. Because of the increased reimbursement, there are billing stipulations that must be followed. These stipulations can be tricky for those who have traditionally only billed for non-FQHC physicians.
  • FQHC rate services must be face to face, with a qualifying provider (physician, nurse practitioner, physician assistant, certified nurse midwife, clinical psychologist, or clinical social worker). Services are bundled into CPT® code T1015 Clinic visit/encounter, all-inclusive for Medicaid with the FQHC’s current rate as the charge, along with all other services listed on the claim. For Medicare claims, there are encounter codes to append on the claim (G0466 new patient, G0467 established patient, G0468 initial preventive physical examination (IPPE)/ annual wellness visit [AWV], G0469 new mental health, G0470 established mental health), along with the services provided for the day.

FQHC Fees Must Incorporate Sliding Fees

FQHCs receive a higher rate for their Medicare and Medicaid population, but also must operate at a sliding-fee for the uninsured. Patients complete a financial assessment based on the federal poverty guidelines to determine if they are eligible to receive discounted services. There are different ways to determine how to charge for each eligible discount slide; however, the easiest practice is to deem an all-inclusive charge for each slide, depending on where the patient qualifies.
It’s vital to carefully look at each service your FQHC provides and complete a cost analysis. This measure will let you provide services to those who cannot afford traditional costs and still keep a healthy revenue cycle.
For example, FQHCs who employ specialty physicians — who typically come at a higher cost, and generate charges at a higher relative value unit than traditional primary care providers — should consider offering their discount sliding fees at a percentage of charges versus a flat all-inclusive rate for high dollar services such as surgeries and minor procedures. Communication between billing and front office staff is essential to make this a seamless process when checking patients in to see the providers.
Federal poverty guidelines update each year, making it essential for all front office staff to have a copy of the current year’s guidelines, as well as a clear copy of the facility’s sliding fee schedule. Such schedules are typically labeled A-F, with Level A being the lowest charges and Level F being full price and not qualifying for a slide discount.
Differentiate each service type so staff can clearly identify what to charge a given patient for a given visit on a particular day. For example, facilities might have a row labeled “Office Visits,” with a dollar amount indicated for each “level” on the sliding fee scale for every evaluation and management (E/M) service code. Surgical procedures may be labeled on their row, as well, and those charges may have a percentage of charges assigned to each slide level. For example, the patient is having a colposcopy. The full-price office charge is $225. According to the sliding scale, the patient qualifies to pay 25 percent of the total. The patient is charged $56.25 at check-in, with the remainder of the charges falling under the sliding fee adjustment transaction.

Balance Your Payer Mix

An additional challenge in an FQHC is achieving a healthy payer mix during your scheduling process. This applies to any type of practice but the revenue burden in an FQHC can become especially acute if you are not managing the schedule properly — especially for specialties that provide services with global fees (e.g., services that include all related or follow-up care within a specified period) such as OB/GYN. A well-balanced schedule, comprising of every payer type, will keep a steady revenue stream without any risk of gaps in payment processes due to heavy scheduling of one type of visit, service, payer, etc.
FQHCs must easily accommodate walk-in patients, which can be of any payer type: You must work carefully to accommodate such patients. Allowing for gaps when scheduling appointments can involve some trial and error that becomes easier as you find patterns in how particular providers’ daily schedules trend. For example, some providers may have a higher “no show” rate for patients or may be busier with scheduled patients during certain times of the year.

Know Your Payer Contracts

Due to the higher percentages of commercial insurance members using FQHCs for their healthcare, it’s important for you to know their commercial contracts and to be able to navigate a traditional contracted insurance’s billing and coding processes. FQHCs are bound by traditional contracts of commercial carriers, but those contracts must be worded to allow the FQHC to employ the sliding fee process for members who qualify for the slide discount based on their income. Even though FQHCs are now permitted to offer a discount to members with high deductible plans who qualify, without that specific wording in your commercial contracts, you could find yourself in violation of that contract. Contracts apply specific rules instructing providers on their responsibility to collect copays, deductibles, etc., in full.

Know Your Bundles, Claim Forms

Coding services in an FQHC requires you to know which CPT® codes are considered part of more extensive services (e.g., bundled, included in). Health Resources and Services Administration provides documentation as reference for coders and billers to determine which services may be billed with a qualifying visit versus a traditional contracted fee-for-service (FFS) rate.
Billing for services may be intimidating, initially, because there are specific payer requirements for claims submission. Most will want these services billed on a UB-04, and non-qualifying visits on a CMS-1500 form; however, there may be times when a payer dictates for all services in an FQHC to be billed on the CMS-1500 form. Revenue codes and UB-type of bill codes can vary, as well, making it essential to have billing staff who can easily differentiate the claims submission process for each type of visit, to each type of payer, and for each type of service the facility is providing. Staff must be able to handle simultaneously traditional billing processes along with those of an FQHC.
Experiencing the FQHC process will keep you well versed in the field; and with continuous practice and education, you can prove to be a vital asset to the revenue cycle process of any practice, not just an FQHC.

Amanda G. Raveaux, CPC, CPB, CPPM, CFPC, CH-CBS, is a billing supervisor at C.H.A.N.G.E., Inc., Community Action Agency in Weirton, W.Va. The agency received designation as an FQHC in 2007, operating as Family Medical Care Community Health Center. She has been a credentialed member of AAPC since 2009, and is a member of the Pittsburgh Central, Pa., local chapter.


8 Responses to “Learn How to Avoid FQHC Billing Roadblocks”

  1. Yvette Cochran says:

    Hello! I’m looking for any FQHC / Orthodontic charge information. Would you be able to help a girl out?

  2. Michelle says:

    When billing for optometry services at a FQHC does it matter whether your diagnosis codes are medical or routine?

  3. Cheryl Rogers says:

    I have a question in regards to New patient visits. If a provider joins our group and his patients from his previous group or practice follows him, is an FQHC able to bill a new patient visit? I am following CPT guidelines, but my managers say this guideline does not apply to an FQHC, if this patient had never been seen at the FQHC location. I have copied and pasted the below from the Medicare Benefit Policy Manual Chapter 13.
    When I read this I still go back to the CPT guidelines. Does the underline not apply to a new provider that has just joined the group, but has seen the patient within 3 years at a previous group not associated with our clinic?
    New Patient Adjustment: The PPS payment rate is adjusted by a factor of 1.3416 when an FQHC furnishes care to a patient who is new to the FQHC. A new patient is someone who has not received any Medicare-covered professional health service (medical or mental health) from any site within the FQHC organization, or from any practitioner within the FQHC organization, within the past 3 years from the date of service.
    I appreciate any assistance on the above. We are in the process of having a new provider join and his patients will be following him. I need to clarify this as the clinic is setting up to bill new patient visits.

  4. jay says:

    I work for a Indian Tribal health center in MI, does anyone know if we can be signed up as an FQHC from Medicare but not one for Medicaid?

  5. R Bolin says:

    How should physicians bill when billing separate from the FQHC when providing services in an FQHC? Should they use the location 50 or would they use an office location 11?

  6. Lori House says:

    Use location 11

  7. kessiah butler says:

    My question – If the facility is FQHC and a patient has visited for a Preventive GYN visit, no problems indicated, comprehensive physical done, however, the FQHC’s payer contract indicates that the GYN Preventive codes are not reimbursable, and will be denied, is there anything, pr another way to be reimbursed for Preventive GYN visits. There is also a concern regarding meeting quality measures and quality initiatives and such in order to meet. specific designated requirements (example: females – required to have annual GYN checkup, annual Pap Ca Screening, Breast Ca Screening, etc). There are requirements to meet to assure the payer that the patient is getting quality care and the FQHC wants to be assured that it is coding correctly to be able to report correct and consistent data. The coding is the main source for reporting data about case mix and visit types.