Industry Perspectives: Tackling Coding Challenges at FQHCs
By Wendy Coplan-Gould, RHIA
For The Record
Vol. 32 No. 1 P. 8
As health care organizations move to value-based payment, federally qualified health centers (FQHCs) face a unique set of coding and reimbursement challenges.
In this roundtable discussion, HIM and revenue cycle experts offer valuable insights gained from their experiences working with FQHCs. Their responses focus on coding and revenue cycle challenges, lessons learned, and successful strategies to achieve optimal reimbursement.
The discussion is moderated by Wendy Coplan-Gould, RHIA, founder and CEO at HRS, a national HIM consulting company specializing in coding integrity, revenue cycle, and workflow process improvement. Joining the discussion are Steven D. Weinman, MBA, CFO and senior FQHC consultant at AITHOZ, which helps health care leaders improve processes and profitability to achieve a thriving business and better patient outcomes, and Jack M. Weir, Jr, CHBME, president of AITHOZ.
For background, FQHCs qualify for enhanced reimbursement from Medicare and Medicaid as well as other benefits to provide comprehensive services, including the following:
• preventive health;
• mental health and substance abuse;
• transportation services necessary for adequate patient care; and
• hospital and specialty care.
WC-G: How is FQHC coding different from other types of coding, especially in terms of reimbursement?
SW: FQHCs are subject to the guidelines of a prospective payment system established by the Centers for Medicare & Medicaid Services (CMS). This method of reimbursement is based on a predetermined, fixed amount regardless of level of care. Because visits are often reimbursed at a fixed rate, there’s a tendency for some FQHCs to underestimate the importance of proper coding. Unlike in the private sector where overcoding is often an issue, FQHCs suffer from chronic undercoding.
Despite reimbursement at a fixed rate, FQHCs are responsible for coding each visit correctly. Any difference in rate should be handled by contractual adjustment for factors such as locality and wellness visits. 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. Though CMS does not perform routine audits for coding accuracy, a suspected problem or complaint will prompt an audit.
WC-G: In your experience, what are the specific coding challenges faced by FQHCs as demands for integrative services increase?
JW: As FQHCs expand service lines, adding nuanced or specialty coding is a problem for coders who don’t understand those details. Staffing to ensure quality and accuracy is a huge challenge. Unlike private practice, FQHCs offer vision care, behavioral health, general practice medicine, internal medicine, obstetrics, and a growing number of diverse services. Most coders in these clinics are familiar with only one or two areas. The challenge is finding well-rounded coders who have the expertise to accurately and efficiently code a variety of specialties.
SW: Another factor that makes FQHCs different from private practice is that those who run the organizations don’t come from an environment where payment is based on coding quality. As a result, budgets typically do not include a line item for coding staff. Furthermore, many health centers use part-time or volunteer providers for some of the work. It is 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. Both can cause challenges in terms of computer literacy and understanding the principles of coding, which can be problematic on the billing side.
WC-G: As health care organizations are pushed by CMS to take on more risk, how will FQHCs be affected?
SW: More FQHCs are getting involved in at-risk contracts, and typically they’re not comfortable with risk. The people negotiating the contracts are not the people providing care, coding, and training. At the same time, FQHCs realize they don’t have the internal knowledge and expertise to ensure proper coding for everything they’re doing. They can either hire coders with experience in various specialties or hire general coders and teach them the specialties. It is costly to hire so many staff to accommodate many specialties.
FQHCs are at a crossroads with expanding credentialed coding staff or looking at alternatives to achieve optimal coding of their encounters. As a viable option, some centers are considering a coding partner that offers efficiency and expertise in specialty areas.
WC-G: It’s important to convey how to code, why to code, and the impact on reimbursement. What are some of the most critical billing challenges for FQHCs?
JW: One of the most prominent challenges is ensuring proper data collection—verification and eligibility of patient coverage on the front end. We’ve solved various problems, including issues with software clearinghouse configurations and staffing challenges. In many cases, there’s a high rate of staff turnover due to lack of training, process, and policy.
SW: Unfortunately, the people responsible for entering demographic and other important data are often the lowest paid in the organization. To address lack of productivity, we work with organizations to determine the required skill level and appropriate compensation for the job. It’s better to pay fewer proficient staff at a higher wage than risk lost revenue.
JW: The second biggest problem is related to system configuration, staff training, and proper use of practice management and EMR systems. For example, some organizations are still using codes from 2015. Failure to update the coding database and conduct staff training can seriously impact billing and revenue integrity.
SW: The problem is exacerbated by confusion around setting fees. For FQHCs, fees should be based on two factors. First, consider your market to make sure fees are comparable to those of other providers. Second, determine the cost to provide service. We find that many FQHCs have set the fee schedule way too low. Best practice is to adjust the fee schedule annually to reflect the market.
In addition, most FQHCs are not-for-profits governed by a board of directors that must include a majority of patients. Those members tend to favor lower charges. It is essential to explain that the best way to address costs to patients is not by setting low charges but by appropriately applying discounts to charges so insurance companies are billed at full charge.
JW: The third biggest challenge in terms of impact to revenue cycle is proper credentialing and enrollment of providers. Revalidation rules have changed. Provider credentialing and enrollment should be handled by qualified people who understand the process.
SW: Proper credentialing requires experience in dealing with insurance companies. It’s not uncommon for health centers to divide the job among several people who have no such experience. For example, an administrative assistant in HR may be assigned to do credentialing. Failure to complete the process accurately and completely leads to out-of-network claim rejections that impact reimbursement. Health centers must make sure the credentialing process is handled by staff whose expertise includes work with health plans. Centralization of the process seems essential to accuracy and efficiency.
JW: Finally, FQHCs face a broad range of claim denials, medical record requests, and coordination of benefits issues. Because health centers lack trained staff to properly work denials, accounts receivable increase along with the number of denied claims—a mounting threat to accurate reimbursement.
WC-G: Most health care organizations are struggling to adapt and grow in today’s complex regulatory environment. Based on lessons learned from your experience, suggest strategies for FQHCs to address coding, billing, and reimbursement challenges that negatively impact revenue integrity.
JW: Start at the front end. Define your workflow process. Tie to policies, procedures, and education. Consider learning management systems and other ways to train people when there’s turnover. Make sure practice management and EMR systems are properly configured with updated codes and accurately structured templates.
Seek help with credentialing and enrollment services. Provide intensive training and education from the accounts receivable side.
Ensure staff expertise in billing and denial management. 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.
Invest in people, processes, and technology to manage denials. An efficient workflow process with qualified staff focused on denial management can generate significant revenue for the organization.