Understanding FQHC Medicare Advantage Wrap Reconciliation: Maximizing Your Reimbursements

FQHCs, Medicare Advantage, Wrap-Around Payments, Healthcare Reimbursement, Revenue Optimization 

Why Medicare Advantage Wrap Reconciliation Matters Now 

While potential Medicaid cuts have many healthcare providers concerned about future funding, Medicare Advantage programs remain stable. This presents a critical opportunity for Federally Qualified Health Centers (FQHCs) to optimize their Medicare Advantage Wrap-Around Payment processes and maximize reimbursements from this reliable funding source. 

Many health centers have fee-for-service contracts with Medicare Advantage plans but aren't submitting Wrap-Around claims for various reasons. In today's uncertain healthcare funding landscape, it's more crucial than ever that FQHCs capture every dollar they're entitled to receive. 

What is the Medicare Advantage Wrap-Around Payment? 

The Medicare Advantage Wrap-Around Payment is a supplemental payment designed to bridge the gap between the payment rates of Medicare Advantage plans and the Prospective Payment System (PPS) rates for FQHCs. This payment ensures that FQHCs are reimbursed at 100% of reasonable costs for services provided to Medicare Advantage enrollees, less any patient cost-sharing amounts. 1, 2 

Why Reconciliation is Essential 

Reconciliation is a critical process that ensures FQHCs receive the correct wrap-around payments. It involves comparing the payments received from Medicare Advantage plans with the PPS rates and identifying any discrepancies. Accurate reconciliation helps FQHCs maintain financial stability and continue providing essential services to their communities. 2 

The FQHC Medicare Advantage Wrap Reconciliation Process: Step by Step 

1. Contract Submission 

  • Submit your Medicare Advantage contract information to the appropriate Medicare contractor 

  • Include documented estimates of average visit payments for MA enrollees2 

2. Rate Comparison 

  • The contractor compares your PPS rate with the MA contract rate 

  • If the MA rate is lower (which is common), the contractor pays the difference as a supplemental wrap-around payment2 

3. Detailed Claim Documentation 

  • Provide comprehensive lists of claims that support your rate calculation 

  • Ensure all documentation is accurate and complete to avoid processing delays2 

4. Payment Adjustment 

  • The contractor adjusts payments to ensure your FQHC receives the correct wrap-around amount 

  • Adjustments account for any cost-sharing amounts owed by beneficiaries2 

Common Challenges in FQHC Medicare Advantage Wrap Reconciliation 

FQHCs often encounter these obstacles when managing wrap-around payments: 

  • Payment rate discrepancies: Differences between expected and received payments 

  • Administrative complexity: Navigating the detailed documentation requirements 

  • Resource constraints: Limited staff time for managing the reconciliation process 

  • System limitations: EMR and billing systems that aren't optimized for tracking these payments 

Strategic Recommendations to Maximize Your Medicare Advantage Reimbursements 

1. Optimize Your Revenue Cycle Management 

  • Audit your Medicare Advantage claims process: Identify any gaps where wrap-around claims aren't being submitted 

  • Configure your EMR system properly: Ensure your electronic records system is set up to flag eligible encounters 

  • Implement automated tracking: Use reporting tools to monitor the status of wrap-around payments 

2. Enhance Staff Training and Awareness 

  • Educate billing staff: Ensure your team understands the wrap-around payment process 

  • Designate a Medicare Advantage specialist: Assign responsibility for oversight to a specific team member 

  • Conduct regular updates: Keep staff informed about any changes to Medicare Advantage policies 

3. Establish Robust Reconciliation Procedures 

  • Maintain detailed records: Create systems for tracking all claims and payments 

  • Schedule regular audits: Conduct quarterly reviews to identify and address discrepancies 

  • Document all communications: Keep records of interactions with Medicare contractors 

4. Leverage Data Analytics 

  • Analyze payment patterns: Look for trends in rejected or underpaid claims 

  • Compare against benchmarks: Evaluate your performance against similar FQHCs 

  • Forecast potential revenue: Project the financial impact of improved reconciliation processes 

Taking Action: Next Steps for Your FQHC 

  1. Assess your current process: Evaluate how effectively you're capturing Medicare Advantage wrap-around payments 

  2. Identify improvement opportunities: Determine specific areas where your reconciliation process could be enhanced 

  3. Implement targeted changes: Focus on the highest-impact improvements first 

  4. Monitor and adjust: Track your results and refine your approach as needed 

 The Medicare Advantage Wrap-Around Payment system represents a vital and stable funding source for FQHCs. By mastering the FQHC Medicare Advantage Wrap Reconciliation process, your center can secure the full reimbursements you're entitled to, supporting your mission to serve underserved communities even during uncertain times for healthcare funding. 

Expert Guidance When You Need It 

Community Link Consulting specializes in helping FQHCs navigate complex reimbursement processes, including Medicare Advantage Wrap Reconciliation. Our team of experts can help you identify opportunities, implement best practices, and maximize your Medicare reimbursements

Have questions about FQHC Medicare Advantage Wrap Reconciliation or need assistance optimizing your process? Let the specialists at Community Link Consulting help you navigate this complex but valuable funding source. 

Phone: 509-226-1393 
Email: info@communitylinkconsulting.com 

Monique Dumond, CPA, Lead Consultant 

Community Link Consulting  

Medicare Technical Assistance https://iweb.nachc.com/downloads/products/85.pdf Medicare Technical Assistance ISSUE BRIEF #85 UPDATE: THE MEDICARE ADVANTAGE “WRAP AROUND” PAYMENT FOR FEDERALLY QUALIFIED HEALTH CENTERS (FQHC) December 2005 Prepared for NACHC by: Adam J. Falk 

Medicare Advantage Wrap-Around Payment - JE Part A - Noridian https://med.noridianmedicare.com/web/jea/provider-types/fqhc/medicare-advantage-wrap-around-payment