Strengthening the FQHC Revenue Cycle


Areas of opportunity health centers can focus on to improve the overall financial outcomes of the center.

Federally Qualified Health Centers (FQHCs) are safety net providers who offer services typically given in an outpatient clinic. FQHCs are unique, operating under a different model and mission, providing high quality care to the nation’s economically disadvantaged and uninsured in our urban and rural communities. FQHCs step up to serve those in need, opening their doors to those with nowhere to turn.

Ensuring efficient and effective revenue cycle processes in a FQHC is crucial. The lifecycle of a FQHC patient begins when the patient is scheduled and ends when the account is paid or denied. There are areas of opportunity throughout the Revenue Cycle continuum. A few areas of opportunity health centers can focus on to improve the overall financial outcomes of the center are:

1. Financial Clearance
The health centers’ front-end Revenue Cycle processes must include workflows to verify insurance coverage at the time the appointment is set, and best practices include integrated technology with the health centers practice management platform. This affords the center with the opportunity to know upfront the patient’s financial responsibility and allows the center to have discussions with the patient prior to service regarding their co-pay and or deductible responsibility.

For those patients who are uninsured, a strong upfront financial clearance process allows the registrar to discuss Medicaid eligibility and other insurance options.

As health centers strengthen their front-end processes, it is important to determine the effectiveness of newer workflows by:

  • Monitoring the percent of patients who are pre-registered and verified prior to service. Best practices pre-verify and register 95% or greater.
  • Evaluating denials related to lack of coverage or authorization. If benefits are truly verified prior to service, then lack of coverage denials should be non-existent. Track and trend eligibility related denials to refine your processes and education of your staff.
  • Monitoring patient responsibility amounts not collected at time of service and use for education to your front-end staff.

2. Staying Current with Fee Schedule and Reimbursement Changes
The Calendar Year 2019 Physician Fee Schedule Final Rule included two new provisions specific to health centers. Below is a summary of the 2019 CMS updates for FQHCs:

  • CY 2019 Medicare FQHC PPS RateEach year the Medicare FQHC PPS is updated using an FQHC specific marketbasket. This year’s marketbasket reflected a 1.9 percent increase, bringing the nationwide PPS rate to $169.77. Remember that the PPS rate is adjusted for geographic location and those adjustments can be found on the CMS website.
  • Payment for Care Management ServicesSince 2016, CMS has reimbursed FQHCs for Chronic Care Management services. In the final rule, CMS added new code (99491) which corresponds to 30 minutes or more of CCM furnished by a physician or other qualified health care professional, similar to CPT codes 99490 and 99487 to the calculation of G5011. Beginning January 2019, FQHCs will be reimbursed for two codes:
    • General Care Management (G5011): includes CPT codes 99490, 99487, 99484 and 99491 – the newest addition. This code should be used when any of the above CPT codes are provided.
    • Psychiatric Collaborative Care Management (G0512): includes CPT codes 99492 and 99493, for at least 70 minutes of collaborative care management. There are no change in the CPT codes for this G code.
  • Beginning January 2019, CMS will reimburse FQHCs for the following new services:
    • Communication Technology Based Service – When an FQHC provider does a “virtual check in” with their patients – a non-face-to-face visit, using communication technology, as long as it is not related to a face-to-face visit within the last 7 days or does not lead to a visit within 24 hours (or the soonest available appointment) with the patient.
    • Remote Evaluation – FQHC providers can receive reimbursement for the evaluation of recorded video and/or images, as long as it is not related to a face-to-face visit within the last 7 days or does not lead to a visit within 24 hours (or the soonest available appointment) with the patient. For remote evaluation, CMS is waiving the “face-to-face” requirement typically required to trigger payment at an FQHC.

3. Denial Management
There is nothing more frustrating than knowing a patient is covered by insurance and receiving no payment from the payor due to a technicality. It is imperative for FQHCs to assign staff to monitor denial reasons and provide adequate staff training to prevent future errors.

  • Use automation through your practice management system that allows the FQHC to set tasking alerts when an account has not been paid in a timely manner and prioritize work for your billing staff.
  • Developing dashboards and aging reports will provide visibility into billing operations.
  • Transition efforts into full denial prevention by using historical denial patterns and trends. Categorize denials by functional area:
    • Registration
      • Eligibility denials
      • Authorization denials
    • Charge Capture:
      • Diagnosis denials
      • Modifier missing or invalid,
    • Provider related issues:
      • Services not supported by documentation,
      • services not covered,
      • provider not eligible or credentialed
    • Billing:
      • Duplicate claim
      • Missing information

Overall, Denial Management is not a one and done initiative. It is an ongoing process improvement initiative that will evolve over time. The health center will require a strong denials management foundation that can support new payor requirements and changes in addition to center personnel fluctuations.

In conclusion, these are just a few, but there are many factors that influence the revenue cycle of FQHCs. It’s important for organizations to note key performance indicators and metrics in order to identify opportunities and disconnects for continuous improvement in the unique FQHC space. Reach out to a Withum advisor to ensure that your health center’s revenue cycle is effective and to seek ways to improve.

For more information on this topic, please contact a member of
Withum’s Healthcare Services Group by filling out the form below.

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