By: Johanna Heller
As we come out of the years of a surplus of COVID funding, that forced us to enhance our grant tracking skills in the operation and finance departments, we are finding that many have lost sight of their consistent revenue stream, the revenue generated from providing care to our patients, patient revenue.
Do you realize that patient revenue, typically seen as the most dependable income stream, often harbors the greatest potential for enhancement and growth?? Why is patient revenue so hard to master? You provide a service, and get paid. Right? Well, it’s not quite that simple.
The intricacies within your patient revenue overshadow the simplicities. It's that straightforward. Quite often, there lie abundant opportunities for enhancing cash flow within your Revenue Cycle Department.
Let me walk you through the big 4 in the payor mix for FQHCs and FQHC Look-A-Likes
Sliding Fee: The sliding fee discount program is a particularly distinctive feature specific to FQHCs and FQHC-LALs. According to Chapter 9 of The Health Center Program Compliance Manual, health centers are required to provide a discount program for individuals whose annual incomes are less than 200% of the Federal Poverty Level (FPL). Moreover, it directs these centers to conduct their entire program in such a way that no individual is refused services due to their inability to pay.
So easy to operationalize, right? Again, not quite that simple. Setting up the application so it’s deployed by health center front office staff accurately, is a very difficult task in itself. We all love when it’s single audit time and the discount program is tested... The sliding fee program is not a revenue enhancer, but a compliance issue, yet worth speaking about in relation to your untapped revenue stream.
Now, there is getting this discount application completed accurately, then there is taking it a step further. How do we use this tool to improve our untapped patient revenue stream? Are you using this as a screening to see if people qualify for Medicaid in your state or other insurance programs? Is it efficient enough, that you could catch those that qualify for Medicaid or other programs and help them complete an application right then and there? Are patients informed prior to their appointment to bring in all they need for the application to their first appointment? What if they forget, what’s your back up plan?
You thought we were going to talk about diagnosis codes and modifiers in this article, didn’t you?
Now let’s discuss the Medicaid program(s). Each state is a little different with varying ranges of complexity, capitation plans, credentialing, Accountable Care Organizations (ACO), T1015s, PPS rate vs APM rate, Change in Scope, triggering events, attribution lists, automatic assignments. OH MY, this sounds complicated....
When is the last time you did a change in scope (if your state has a process). Do you know what metrics you need to participate in an ACO to get an equity distribution, if there is one to have? Does your ACO know? Is your billing system automatically attaching T1015s to the proper claims or is that a manual process, setting up room for human error and potentially costing you thousands. Do you even know… is your billing outsourced and out of your control?
The complexities within Medicaid programs require clinical operational excellence and billing department excellence to ensure your patient revenue stream is optimized.
The 3rd of the big 4 payors, Medicare, includes its own range of complexities, from credentialing, PTANS, Cost Reports, consolidated sites, Medicare WRAP, Annual Wellness Visits, Chronic Care Management, different intermediaries, quarterly credit balance reporting, to name a few. Are your FQHC G Codes set higher than the PPS rate Medicare is willing to pay? And can you justify the rate they’re set at?
Deploying Medicare Annual Wellness Visits and Chronic Care Management can be an operational nightmare, but when done right you are set up for a good income stream and care for your patients. Additionally, we find many clinics are unaware of the Medicare WRAP around payment they can take advantage of.
The 4th big payor in the traditional payor mix of an FQHC or FQHC-LAL is private/commercial insurance. Once again, with a number of complexities within contracting, contract negotiation, credentialing timelines, timely filing, quality care payments and clinic fee schedule implications. Ensuring organization and tracking around insurance provider credentialing is easier said than done. Are you charging more than your private insurance companies are willing to pay? Because if you’re not, you can be sure they won’t pay you what they’re willing to pay if your charge is set less.
In addition to all this, have you reviewed your fee schedule to ensure alignment with the requirements set forth in Chapter 16 of The Health Center Program Compliance Manual? Have you reviewed your contracted rates with insurance plans and is their allowable fee schedule set to maximize reimbursement? Are there insurance plans you are not contracted with that you may want to be?
Optimizing provider schedules and maximizing utilization is another way of improving patient service revenue. You’d be surprised to find how many provider templates are set up that limit specific visit types so much that it significantly impacts patient access. This can include a disproportion of administrative time to patient facing time that limits productivity and patient access. When was the last time you actually reviewed your provider schedule templates?
Grants are great – but make sure you’ve tapped that one consistent revenue stream, patient revenue, to increase your financial stability. And don’t forget CLC can help, reach out to us today (info@communitylinkconsulting.com) if you are interested in support!