FQHC Revenue Cycle & Reimbursement Optimization

FQHC Revenue Cycle & Reimbursement Optimization

FQHCs receive reimbursement from Medicare and Medicaid through the Prospective Payment System (PPS) — an encounter-based rate that, when properly managed, significantly exceeds standard fee-for-service rates. But capturing that reimbursement accurately requires correct coding, clean claims, properly scoped encounters, and a billing team that understands the specific rules governing FQHC visits.

Many health centers are unknowingly under-billing, miscoding billable services, or failing to claim reimbursable visits altogether. Our revenue cycle team brings an FQHC-specific lens to every assessment — not generic billing advice, but expertise built around the health center model.

Service Areas

- PPS Rate Analysis — Evaluation of your current all-inclusive encounter rates and identification of opportunities to increase reimbursement through scope of service adjustments

- Coding & Documentation Review — Audit of clinical documentation and coding practices to ensure billable services are accurately captured and supported

- Denial Management — Root cause analysis of denied claims with corrective action plans to reduce recurring denial patterns

- Sliding Fee Scale Review — Assessment of your sliding fee discount program structure for compliance with HRSA requirements and patient access best practices

- Payer Mix & Managed Care Contracting — Analysis of your payer mix and guidance on Medicaid managed care contracts involving FQHC-specific reimbursement

- Billing Staff Training — Training for billing and coding teams on FQHC-specific rules, including same-day visit billing, mental health add-ons, and dental visit coding

- Financial Sustainability Planning — Forward-looking financial modeling tied to service expansion, new payer contracts, and reimbursement rate projections

What We Deliver

- Revenue Cycle Assessment Report — A written analysis of current billing performance, identified gaps, and quantified lost reimbursement

- Corrective Action Roadmap — Prioritized, actionable steps to improve collections and reduce revenue leakage

- Coding & Documentation Guidelines — FQHC-specific reference materials for clinical and billing staff

- Ongoing Revenue Monitoring — Monthly or quarterly performance reviews tied to key revenue cycle metrics