What is an FQHC?

FQHC stands for Federally Qualified Health Center. This is a specially certified clinic established to receive special reimbursement, known as a per diem rate, from Medicare and Medicaid. Clinics with this program improve access to underserved areas and provide services regardless of a patient’s ability to pay. Patients are charged a sliding fee scale based on income and family size.

FQHCs are required to use a team approach and must be staffed at least 50% of the time with mid-level practitioners such as a PA or an NP. Other providers in a FQHC might include a dentist, nutritionist, clinic psychologist, or Certified Nurse Midwife.

FQHCs must submit an annual cost report, the method to reconcile services and payments to allowable costs. The result determines future reimbursement rates. The per diem rate changes on January 1st of every year.

To receive the per diem rate, a face-to-face visit between the patient and the provider must be rendered. Only one face-to-face visit is payable per day, although there are a few exceptions. One such exception might be if the patient had a medical visit and a behavioral health visit on the same day, which would allow two separate per diem payments.

Non-face-to-face visits such as a visit solely for the administration of an injection are not payable. These services are considered bundled with an encounter 30 days before or after and must be adjusted off.

Claims for FQHC services are submitted on a UB-04 claim form. Both CPT and revenue codes are required when submitting claims to Medicare, along with the appropriate code for the encounter. Medicaid utilizes their own encounter codes when processing FQHC services.

Need help determining the ins and outs of FQHC billing? Schedule a consultation with us at Triumph Medical Practice Solutions.

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