How to Get Reimbursed Operating as a Federally Qualified Health Center?

What is a Federally Qualified Health Center?

Federally Qualified Health Centers (FQHCs) are federally funded non-profit outpatient clinics. They exist to provide healthcare to those who are underserved, such as the uninsured and those living below the poverty line. They are also known as Community Health Centers (CHCs).

They get federal support and grants to run their operations and have specific reimbursement systems under Medicaid and Medicare. They offer services to all individuals regardless of their ability to pay and offer a sliding fee discount scale to those patients eligible to pay, based on income and family size.

Benefits of FQHC

There are many benefits to becoming an FQHC clinic. Firstly, you are allotted some funds to start up the clinic. You have access to National Health Service Corps if you are ever struggling to find the right personnel for your HR operations.

But most importantly perhaps, being an FQHC clinic makes you eligible for various federal programs and grants. Especially as the political or economic climate changes, you will be in a position to scale up and affect change to meet the most relevant challenges of healthcare in the US. These include:

Reducing Costs

FQHCs are set up to provide outstanding outpatient services focusing on prevention and primary care. It reduces the need for more costly hospital-based options and specialty care, saving the taxpayer billions of dollars. It reduces costly ED visits by treating preventable and non-emergent conditions.

Increasing Quality of Care

Through value-based payment (VBM) models, FQHCs are able to provide high-quality cost-effective care to their patients. VBM arrangements give FQHCs the flexibility to provide care in ways that best meet the patient’s needs. It takes a coordinated team-based approach that identifies and addresses patients’ health-related social needs. Care coordinators are able to connect patients to relevant community resources.

Improve Patient Experience

FQHCs make a big difference in making healthcare accessible for those who would not have otherwise sought out healthcare for themselves. As they are located in areas that have a shortage of healthcare facilities or professionals, it makes it more convenient for people living in those areas to access healthcare.

FQHC Reimbursement Codes- Qualifying Visits

There are reimbursement codes designated for FQHC. We will be looking at both face-to-face codes and non-face-to-face codes. Face-to-face refers to a situation where the patient and the healthcare provider are on the same premises. It can be an FQHC clinic or at the home of the patient where a Registered Nurse (RN) or a Licensed Practitioner Nurse (LPN) visits them. Non-face-to-face codes refer to remote care where the patient and provider do not have to be in the same location.

FQHC Visit Codes (Face-to-face)

The reimbursement codes below are for an FQHC visit that is either a medically necessary medical or mental health visit, or a qualified preventative health visit. Taken from CMS.

G0466 – FQHC visit, new patient

A medically-necessary medical, or a qualified preventive health, face-to-face encounter (one-on-one) between a new patient, and an FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving an FQHC visit

G0467 – FQHC visit, established patient

A medically necessary medical, or a qualifying preventive health, face-to-face encounter (one-on-one) between an established patient and an FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving an FQHC visit.

G0468 – FQHC visit, IPPE or AWV

FQHC visit that includes an initial preventive physical exam (IPPE) or annual wellness visit (AWV) and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving an IPPE or AWV.

G0469– FQHC visit, mental health, new patient

A medically necessary, face-to-face mental health encounter (one-on-one) between a new patient, and an FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving a mental health visit.

G0470 – FQHC visit, mental health, established patient

A medically necessary, face-to-face mental health encounter (one-on-one) between an established patient and an FQHC practitioner during which time one or more FQHC services are rendered and includes a typical bundle of Medicare-covered services that would be furnished per diem to a patient receiving a mental health visit.

FQHC Visit Codes (Non-Face-to-face)

HCPCS G0511

Refers to General care management, of 20 minutes or more of clinical staff time for chronic care management services or behavioral health integration services directed by an FQHC practitioner (physician, NP, PA, or CNM), per calendar month.

This code can be used to furnish at least 20 minutes of chronic care management services, at least 20 minutes of general BHI services, or at least 30 minutes of PCM services. The services provided can be performed by clinical staff under general supervision.

An FQHC may bill for only one unit of G0511 per beneficiary per month.

The FQHC can count only services from an FQHC practitioner or auxiliary personnel toward the 20-minute minimum requirement for billing general care management services or the 30-minute minimum requirement for PCM services. It should not include administrative activities such as transcription or translation services.

HCPCS G0512

Refers to Psychiatric collaborative care model (psychiatric CoCM), of 60 minutes or more of clinical staff time for psychiatric CoCM services directed by an FQHC practitioner (physician, NP, PA or CNM) and including service furnished by a behavioral health care manager and consultation with a psychiatric consultant, per calendar month.

You can bill G0512 once per month per patient when you deliver at least 60 minutes of psychiatric CoCM services, and your services meet all other requirements.

New Funding for FQHC

The American Rescue Plan Act pledged over $6 billion to Community Health Centers nationwide that include the FQHCs.

The funding is to be used for supporting and expanding COVID-19 vaccination services, delivering preventive and primary health care services to those more vulnerable because of COVID-19, and expanding operational capacity for the pandemic and beyond.

Part of improving operational capacity is cited to be improving infrastructure, of which setting up remote care capability is a big part. For example, the Primary Care Development Corporation says that funds can be used for new modalities such as telehealth expansion.

The Primary Care Development Corporation has pledged support to help FQHCs develop organizational workflows and patient communication for telehealth, and integrate behavioral health to support mental health and substance abuse needs. Care management coordination via developing a continuous process of care through care pathways is another focus area.

This year in August, Health Resources and Services Administration awarded more than $19 million to 36 recipients to improve telehealth in their communities. FQHCs should be on the lookout for such funds which are specifically meant to build remote monitoring capacity and better serve their population in rural or underserved areas.

Here are some of the programs this year, that were funded.

FY 2022 Optimizing Virtual Care

Available for up to 25 health centers on a competitive basis. Supports health centers to develop, implement, and evaluate innovative, evidence-based strategies. Includes optimization of the use of virtual care.

FY 2021 American Rescue Plan Funding for Health Centers

One-time funding for a 2-year period of performance to support health centers to prevent, mitigate, and respond to COVID-19 and to enhance health care services and infrastructure.

FCC COVID-19 Telehealth Program Additional Funding

Funds the purchasing of telecommunications services, information services and devices needed to provide connected care services during the public health emergency.

USDA Distance Learning and Telemedicine Grants

This program aims to overcome the adverse effects of remoteness and low population density in rural communities, by furnishing them with tools to increase connectivity.

The Connected Care Pilot Program

Supports the expansion of telehealth access, specifically to low-income Americans and veteran patients by helping cover health care provider costs.

Centene Grant

Provides funding with the goal of increasing sustainability of telehealth solutions for FQHCs just starting programs or looking to build upon them.

FY 2021 Supplemental Funding for Hypertension

Expands access to hypertension diagnosis and control through RPM support and must be used for in-scope services.

Private Investments for FQHC

Federal investments aside, there are other private sector investments one should keep track of. There have been many foundations in the past that have both guaranteed funds and provided financing to improve and expand FQHCs.

United Healthcare Community & State has partnered with FQHCs to expand access to care and improve outcomes for millions of Americans. Addressing those with chronic conditions and integrating behavioral and physical health have been two pathways targeted by these transformational investments. To address such issues, two-thirds of the recipient FQHCs have focused on building telehealth and digital engagement capacities.

What to Know as an FQHC

This public health emergency period has broken down walls on the hesitations around using telehealth. The FCC has made almost $250 million available in new funding as a part of its ongoing efforts to push pandemic-related telehealth initiatives.

Just as any private care practice or healthcare facility can offer remote patient monitoring or chronic care management services to their population, an FQHC can do the same. Both lines of services require some element of a telehealth program. Additionally, there are other federal grants such as those provisioned by the HRSA to lead such efforts.

It’s important for FQHCs to take advantage of such support and provide both face-to-face and non-face-to-face services to their catchment area.

CMS is proposing to “revise the current regulatory language for FQHC mental health visits to include visits furnished using interactive, real-time telecommunications technology. ”FQHCs are currently authorized to serve as distant site practitioners for Medicare telehealth services because of the COVID-19 public health emergency(PHE).

Under the new proposal, even after the end of the PHE, FQHCs will be able to report and receive payment for mental health visits furnished via real-time telecommunication technology.

In light of all the recent developments, it’s a good opportunity to contemplate innovative remote care programs for FQHC programs and providers. The injection of funds signals the nation’s intention to move in a direction where healthcare is more inclusive for all. FQHCs certainly, will have a major role to play in that endeavor.