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Medicaid and FQHC Billing for Dummies

Apr 16, 2024 12:30:00 PM / by Altruis

FQHC Billing for dummies

Medicaid payments are a vital source of revenue for a community health clinic. As a federally qualified health center (FQHC), your practice relies on receiving a steady flow of Medicaid reimbursements.

FQHC Billing for Dummies: Top 7 Medicaid and FQHC Billing Tips

This article covers the best billing practices to ensure prompt and full Medicaid reimbursement. We’ll also address common questions about Medicaid collections and how FQHC billing companies make a positive impact on revenue generation.

Preverify Eligibility

Before providing medical services, confirm patients are eligible for Medicare coverage. This step is known as preverification. When patients can’t be preverified and are ineligible, Medicare reimbursement is unlikely unless they later become eligible through retroactive coverage, which is discussed below.

Send Clean Claims 

Submit clean claims that are right the first time, every time. A clean claim has no improper information that would cause it to be rejected. Unclean claims typically contain incorrect billing codes, blank fields, misspellings in patient details, incorrect dates, or otherwise fail to follow Medicare claims processing rules.

Utilize Medical Coding Correctly

Do your clinic’s claims always include accurate codes Medicaid will accept? Kaiser Family Foundation research on Medicaid and Medicare claims shows about 14% are denied because they request reimbursement for excluded services.

This can signal a coding problem, where incorrect codes are being entered for services rendered to Medicare-eligible patients. The clinic’s medical associates may need more coding training or an outside partner may be needed to assist with proper coding procedures.

Use the Latest Technology

Minimize rejected claims by digitizing your process. Digitization prevents errors and allows easier tracking of Medicaid claims. All documentation can be uploaded to the digital platform and submitted directly to Medicaid for reimbursement. 

Track Performance Metrics in Your FQHC Billing System

Clinics that track key performance metrics (KPIs) tend to see red flags earlier and prevent problems with Medicaid reimbursement. For example, the clean claims rate can reveal whether your location needs to refine its processing methods to accomplish more first-time paid claims.

Stay Ahead of Regulatory Changes

Healthcare regulations change constantly and it’s essential to stay ahead of any new rules that involve Medicaid billing. New medical billing and coding changes could have a significant impact on a clinic’s revenue stability, so educate your associates as soon as possible.

Work with Reputable FQHC Billing Companies

The nation’s best FQHC billing companies use industry-leading revenue optimization strategies to drive high rates of Medicare reimbursement. If your clinic is struggling to collect Medicare payments, consider partnering with a billing specialist to ease the burden and ensure the highest possible level of reimbursement.

Common Questions About Medicaid Reimbursement

In the daily course of collecting Medicaid payments, associates may encounter challenges that exceed their knowledge about the process. Here are the answers to common questions.

Is it Normal for Medicaid Claims to Be Rejected?

Medicaid claims are often rejected when they contain erroneous or missing information, are submitted too late, or aren’t for covered services. Claims may also be rejected when the patient has other applicable forms of coverage but Medicaid was billed first.

Can Medicaid Be Backdated?

Retroactive eligibility occurs when someone later becomes eligible for Medicaid coverage that was not available or obvious at the time of service. Can Medicaid be backdated? Yes, but only for a short period. This retroactive coverage usually only applies to the previous three months, so you have a fairly narrow window of time to apply it.

Check unreimbursed claims to see if coverage can be backdated to allow Medicaid payment. Backdating through retroactive coverage is a somewhat complex process for someone who is not highly educated about medical billing. Consider working with a retroactive revenue specialist to ensure it’s handled properly.

What Is Medical Redetermination?

Healthcare payment sources, including Medicaid, can initiate a process where they formally review and reassess a previous decision regarding coverage or reimbursement for medical services. This process is called medical redetermination and it can cost a clinic up to 10% of its revenue. 

Redetermination can cause delays, administrative difficulties, and financial uncertainty, all of which can affect a medical facility's revenue unless it has the right procedures in place. Verifying insurance coverage every time is important to alert the organizations when changes may have occurred.  When an FQHC handles redetermination appropriately, it can capture valuable revenue that might otherwise have been lost.

For More Information: Download Our Medicaid Data Sheet

Altruis is dedicated to helping FQHCs accomplish fast, accurate Medicaid claims reimbursement through close collaboration between our team and yours. We’ll fill gaps in billing expertise and work proactively to address your biggest challenges and resolve them successfully.

To learn more about collecting maximum revenue for Medicare-eligible care and Medicaid and FQHC Billing for Dummies, download our RetroPay™ data sheet. It shows how much more revenue you could be claiming from retroactive Medicaid coverage.


Download the Data Sheet


Topics: FQHC Billing


Written by Altruis

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