Who we serve
Clinic billing services for FQHCs, rural health clinics and community clinics
Clinic billing services for an FQHC or rural health clinic turn on the encounter: what counts as one, which form it goes on, what the program pays for it, and how the wrap-around payment is reconciled afterwards.
Remitwright gives clinics a dedicated biller who knows encounter rules, keeps the encounter and non-encounter streams straight, and reports by program and by site.
For private practices, groups and new practices, see medical billing by practice type.
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What is different
What is different about a clinic
- The encounter is the unit. Medicare and Medicaid pay FQHCs and RHCs per qualifying visit, not per service line. A visit that does not meet the encounter definition is not paid as one, however many codes it carries.
- Two claim forms. Encounter claims often go on the institutional form with revenue codes; other services go on the professional form. The same visit can touch both.
- Wrap-around reconciliation. What a managed care plan paid has to be tracked against the state encounter rate, and the difference claimed. Clinics without a reconciliation routine leave it unclaimed.
- Sliding fees and grant rules. Patient balances follow a discount schedule, and the documentation has to satisfy the program and the auditor.
- Reporting by program and site. Funders, boards and the UDS report need numbers cut in ways a private practice never does.
What we do
What we do for clinics
- Encounter claims built to each program's definition, on the right form, with the revenue and procedure codes the program expects.
- Non-encounter services billed under their own rules and kept separate in the reports.
- Managed care payments reconciled against the encounter rate, with wrap-around claims submitted and tracked.
- Sliding fee discounts applied and documented on patient balances.
- Eligibility, authorization, credentialing and denials worked as for any practice, with a dedicated biller and named cover.
- Reports by program, payer, provider and site, cut the way your board and funders read them.
The code families and denial reasons for each program are set out on the FQHC billing services and rural health clinic billing services pages.
- BAA signed before any access
- A user you create and can remove
- MFA on every login that supports it
- Patient data stays in your systems
Worked example: the two-site community health center
A community health center with a medical site and a behavioral health site bills three Medicaid managed care plans. Reconciliation shows one plan has been paying medical encounters correctly but paying behavioral health encounters at a lower rate, and the wrap-around claims for that site were never filed because the two sites report separately and nobody compared them. The biller files the wrap for the open quarters the program allows, sets up a reconciliation by site and plan, and the report now shows encounter counts, plan payments and wrap claims on one page.
Getting started
How it starts
A written review of encounter volume, payer mix, wrap-around status and aging by site, then a quote that sets out scope. How it works covers the five stages.
Questions
What practices like yours ask
Still deciding?
If your question is not here, add it as a note in the review and a billing specialist replies in writing.
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How is FQHC billing different from a private practice?
An FQHC is paid for a qualifying encounter rather than for each service line. Medicare pays a prospective payment per visit under the FQHC PPS, and state Medicaid programs pay an encounter rate, often with a wrap-around payment that makes up the difference from what a managed care plan paid. The claim still has to carry the right codes, but what gets paid, and how, is decided by the encounter rules.
What is a wrap-around payment?
When a Medicaid managed care plan pays an FQHC or RHC less than the state's encounter rate, the state pays the difference, usually through a separate reconciliation. Tracking what each MCO paid against the encounter rate, and claiming the wrap correctly, is the step that leaves money unclaimed when nobody owns it.
Can you bill both the clinic's encounter claims and its non-encounter services?
Yes. Services outside the encounter definition, such as certain lab, dental, behavioral health or pharmacy items depending on the program, are billed under their own rules. Keeping the two streams straight is part of the work.
Do you handle sliding fee discounts?
We apply the discount schedule your clinic sets to patient balances and keep the documentation the program expects. Setting the schedule and verifying income is the clinic's role.
Do you bill on the UB-04 or the CMS-1500?
Both, depending on the program and the payer. Rural health clinics and many FQHC claims go on the institutional form (UB-04 or 837I) with revenue codes; other services go on the professional form (CMS-1500 or 837P). Your biller works in whichever your system produces.
Which clinic systems do you work in?
The practice management and EHR systems clinics commonly use, including athenahealth, eClinicalWorks and NextGen, and the clearinghouses that connect them. Your biller works as a user in your system.
Next step
Ask a biller where your encounter and wrap-around claims stand.
Three quick questions. No patient data. A billing specialist reads every request and replies in writing.
- Three questions, about two minutes
- No patient data, no software to buy
- A written reply from a biller, not a sales deck
You answer three questions
A billing specialist reads them
A written reply by email
Prefer email? sales@remitwright.com
Request received
Thanks. Your review request is in.
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- A billing specialist reads your answers and replies by email.
- If a look at real claims makes sense, we agree read-only access under a BAA first.
- You get a written summary of what is worth working and what it would take. No commitment.
While you wait: see the sample weekly report or read how switching works. You can also download the sample weekly report (PDF).