FQHC & CHC Billing

FQHC & Community Health Center Billing Services

Purpose-built revenue cycle management for Federally Qualified Health Centers — maximizing PPS encounter rates, optimizing wrap-around payments, and ensuring HRSA compliance across every visit type.

$42+ Avg. PPS Rate Increase Captured

100% Wrap-Around Billing Compliance

340B Program Revenue Optimization

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The Challenge

FQHC Billing Is Unlike Any Other

FQHCs operate under a fundamentally different payment model than private practices. The Prospective Payment System, encounter-based billing, cost report reconciliation, and grant compliance create a billing environment that general RCM companies simply cannot handle.

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PPS Encounter Optimization

Under PPS, FQHCs receive a per-visit all-inclusive rate rather than fee-for-service payments. Maximizing revenue means ensuring every qualifying encounter is captured, properly documented, and billed — including same-day visits with distinct providers in different qualifying disciplines.

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Wrap-Around Billing

Medicaid wrap-around payments bridge the gap between the Medicaid encounter rate and the FQHC PPS rate. We ensure wrap claims are filed correctly with state-specific billing requirements, supplemental payment reconciliations, and timely filing to capture every dollar owed.

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Cost Report Support

The Medicare cost report (CMS-224-14) determines your PPS rate. We support cost report preparation by ensuring visit counts are accurate, provider productivity data is clean, and cost allocation aligns with allowable cost centers to maximize your per-visit rate.

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Sliding Fee Schedule

HRSA requires FQHCs to offer services on a sliding fee scale based on family income and federal poverty guidelines. We manage SFS determination workflows, ensure discounts are applied correctly, and maintain documentation for HRSA operational site visit readiness.

Our Approach

Built for the Community Health Model

We understand that FQHCs serve the most vulnerable populations and operate with tight budgets supported by federal grants. Every dollar recovered goes directly toward expanding access to care. Our approach is designed specifically for the FQHC payment model.

Encounter maximization — identifying billable same-day encounters across medical, dental, behavioral health, and enabling services
Provider credentialing for all FQHC-eligible provider types including physicians, NPs, PAs, CNMs, clinical psychologists, and LCSWs
Visit type tracking — medical, dental, mental health, substance use, vision, and enabling services with proper HCPCS coding (T1015, etc.)
Grant budget alignment — ensuring billing revenue is properly allocated against HRSA grant requirements and reported in EHB data
UDS reporting support — clean patient demographic and visit data for accurate Uniform Data System annual reporting
340B program optimization — maximizing drug cost savings while maintaining program compliance and preventing duplicate discounts

FQHC Visit Types We Bill

Complete billing across all qualifying encounter types:

Primary care medical visits
Dental (preventive & restorative)
Behavioral health & psychiatry
Substance use disorder treatment
OB/GYN & prenatal care
Chronic care management (CCM/RPM)
Telehealth encounters
Enabling & case management services

HRSA Compliance

Maintaining Your FQHC Status

HRSA compliance isn't just about billing — it's about protecting the federal designation that your entire funding model depends on. We help you stay audit-ready every day.

Operational site visit preparation — ensuring billing practices, SFS documentation, and financial records meet HRSA program requirements
Scope of project compliance — billing only for services within your approved Form 5A scope and flagging services that may need scope change applications
Board governance documentation — supporting the 51% consumer board majority requirement with proper meeting and decision documentation
Quality measure tracking — UDS clinical quality measures and Health Center Program compliance indicators

Grant & Revenue Alignment

We help FQHCs maintain the delicate balance between grant-funded services and billable encounters. Our reporting shows exactly how your revenue mix breaks down across Medicare PPS, Medicaid PPS/wrap, commercial insurance, self-pay sliding fee, and grant-supported uncompensated care — giving your CFO complete visibility.

FAQ

FQHC Billing Questions Answered

Under FQHC PPS rules, a patient can generate multiple billable encounters on the same day if seen by providers in different qualifying disciplines — for example, a medical visit and a behavioral health visit. We train front-desk and clinical staff on same-day scheduling optimization and ensure each qualifying encounter is properly documented with a distinct provider, separate note, and appropriate billing codes.

Yes. We manage Medicare PPS billing under the all-inclusive rate with proper G-code reporting, Medicaid encounter billing with state-specific requirements and wrap-around payment processing, and commercial insurance billing at your negotiated rates. Each payer requires different claim formats, coding, and follow-up workflows that we handle seamlessly.

We provide clean, reconciled visit data that feeds directly into your cost report preparation. Our reporting breaks down encounters by provider, visit type, and payer — giving your cost report preparer accurate denominators for the per-visit rate calculation. We also flag provider productivity anomalies that could trigger MAC audit inquiries.

FQHC telehealth billing has evolved significantly. We ensure proper billing of audio-video and audio-only visits based on current CMS guidelines, apply correct POS codes and modifiers (95, GT), and track which services qualify for the full PPS encounter rate vs. reduced telehealth rates. We also manage the distant site facility fee billing unique to FQHCs.

We integrate with all major FQHC EHR platforms including eClinicalWorks, athenahealth, NextGen, Greenway/Intergy, and OCHIN Epic. Our workflows accommodate the unique encounter documentation and UDS reporting requirements built into these FQHC-configured systems.

We support both established FQHCs and organizations seeking FQHC status. For Look-Alikes and New Access Point applicants, we help establish billing infrastructure, credentialing workflows, and sliding fee processes before HRSA approval — so you're ready to bill from day one of your designation.