Federally Qualified Health Center (FQHC) billing services involve coding, submitting, and managing insurance claims for primary care, dental, mental health, and other essential services provided at FQHCs. These services require specialized billing to comply with Medicare, Medicaid, and private payer guidelines while maximizing reimbursements.

Some key challenges include:

• Navigating the Prospective Payment System (PPS) rate for Medicare and Medicaid reimbursements
• Managing multiple payer types, including grants and sliding fee scales
• Accurate coding for bundled services such as medical and behavioral health visits
• Ensuring compliance with HRSA, Medicare, and Medicaid guidelines

To minimize denials, FQHCs should:

• Use correct CPT and HCPCS codes with FQHC-specific billing rules
• Verify patient insurance eligibility before services are provided
• Ensure proper documentation to justify medical necessity
• Stay updated on Medicaid state-specific billing requirements

Outsourcing FQHC billing helps:

• Maximize reimbursements while maintaining compliance with regulations
• Reduce administrative burden, allowing providers to focus on patient care
• Ensure accurate claims submission for faster payments
• Navigate complex Medicare/Medicaid reimbursement models efficiently