Choosing the Right FQHC Billing Provider for Your Practice

Created in 1991, Federally Qualified Health Center (FQHC) is a designation for special reimbursement from the Bureau of Primary Healthcare and the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services. FQHC billing providers include all organizations receiving grants under Section 330 of the Public Health Service Act (PHS). FQHCs must meet certain criteria to be designated as such. They must provide comprehensive services (including after-hours care or an arrangement for such) across every stage of life to an under-served demographic (either rural or urban), offer a sliding fee scale based on federal poverty guidelines, have ongoing quality control practices, and have a board of directors by which they are governed. FQHCs typically operate in an outpatient clinic-type setting, but also have admitting privileges at a local hospital or have a “continuity of care” hospital plan in place for all patients they serve. FQHCs are not to be confused with RHCs (Rural Health Centers) or Look-Alikes, who have similar guidelines but different criteria and billing regulations.

FQHCs are reimbursed with an all-inclusive rate by Medicare and Medicaid. They can, however, bill for services separately with appropriate coding and documentation. Failure to submit the appropriate claim forms with the correct CPT and HCPCS codes will result in automatic denial of the claim. The rules, regulations and coding for FQHC billing are constantly evolving and highly specialized, so it is important to have an FQHC billing provider who is on the cutting edge of this industry. A qualified FQHC billing provider will be knowledgeable about proper coding and accuracy for covered items, as well as services that NOT covered, and can effectively reduce the number of outstanding accounts receivable that plague many medical practices today.

Things to consider when choosing the right FQHC billing provider for your practice:

  1. Ensure they have an experienced, reputable staff with expert knowledge of all aspects of FQHC billing and coding, including Medicare and Medicaid, and the differences in (and capability to provide) billing for FQHC Look Alikes.
  2. You want an FQHC billing provider who employs experienced billing experts for the various specialties covered under the comprehensive care services that FQHCs must provide, including: Internal Medicine, OB/GYN, Cardiology, Pediatrics, Dental, Mental and Behavioral Health, as well as services provided under the care of Physicians Assistants (PAs) and Advanced Practice Nurses (APNs.)
  3. Your FQHC billing provider should be trained and able to work efficiently in many of the Electronic Medical Records (EMR) systems utilized by many practices, as this will optimize cycle time and ultimately, increase income for your practice.
  4. The best FQHC billing providers will possess and maintain up-to-date knowledge of, and adhere to all applicable Local, State, and Federal laws, statutes and regulations and operate under a code of legal and ethical business practices to maximize the advantage of their service to your practice.

Ultimately, entrusting your FQHC billing to a reputable and qualified provider should provide you with reduction in overhead expenses, both provider and patient satisfaction with billing competencies and cycle times, and reliability and accuracy you can trust, with proven results for the increased cash flow and income for your practice.


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