• AHAP Inc.

Coding and reimbursement challenges for FQHCs

Since mid-1960s, Community Health Centers have delivered comprehensive, high‐quality preventive and primary health care to patients regardless of their ability to pay. They have become essential in coordinating primary care and preventive services for millions of Americans.


In today's healthcare, and as health care organizations move to value-based payment, Federally Qualified Health Centers (FQHCs) face a unique set of coding and reimbursement challenges. And with the countless challenges that impact healthcare providers today, it has never been more important to properly and sufficiently document to satisfy reporting requirements for the E&M visits, procedures, supplies and other medical and ancillary services that your organization provides.


FQHCs are accountable for coding each visit correctly. However, there is a tendency for some FQHCs to error on the side of caution when assigning procedure codes by undercoding. This is not recommended because it results in substantial lost revenue and creates skewed claims data that ultimately lower reimbursement rates. Undercoding diminishes the value of services provided, which must be reported annually to the federal government. Accurate reporting is in the FQHC’s best interest because it actually supports the amount paid.


Challenges faced by FQHCs


Today, FQHCs are taking on a more prominent role in our healthcare system, providing primary care, as well as multi-specialty services which includes obstetrics/gynecology, 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.


One of these challenges is staffing to ensure quality and accuracy. The challenge is finding qualitied coders who have the expertise to code a variety of specialties accurately and efficiently.


Also, many FQHCs use part-time or volunteer providers for some of the work which in some instances make it difficult for a part-time provider to be proficient with an EHR that is involved in coding. Some providers are retirees while others are medical school graduates just starting out in which it can create a challenge in terms of understanding the principles of coding and can be problematic on the billing side.


In many instances, FQHCs recognize that they do not have the internal knowledge and expertise to ensure proper coding for all of the services they provide. The options are that they can either hire coders with experience in various specialties or provide essential training needed to teach them the specialties which can be costly.


Another challenge that FQHCs face a wide range of claim denials. Since many FQHCs lack trained staff to properly work denials, accounts receivable increase along with the number of denied claims. Nothing is more frustrating to providers and their bottom line as a denied claim.


Strategies to address coding and reimbursement challenges


Provider documentation is vital when deciding on appropriate code selection. It is imperative to familiarize providers, coders, and billing staff on documentation requirements. The best solution for this is to conduct regular training sessions for your medical providers and medical billing staff.


FQHCs need to ensure that their staff the expertise in billing and denial management. If need they should consider outsourcing as an alternative to hiring and training full-time staff. This can be a cost-effective way to ensure experience and expertise in specialty areas.

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