Hello-
I am writing from a clinic that is about to merge with a FQHC look alike. We will begin billing under the FQHC look alike’s status and will receive the PPS rate for eligibile visits. Probably not necessary to say, but I have questions around what this looks like from a billing & compliance standpoint.
Prior to billing as an FQHC look alike, We only see out of network managed care clients for sensitive services. This does not need any type of authorization as long as the diagnosis falls into a grey area that some managed care payors deem a "sensitive service" ie abortion care, family planning, etc. We were never a part of the medical home so we always referred the patients back to their medical home for primary care services as we could not bill and receive payment for these visits for primary care services.
Now, come 11.1.17, we will be billing these same managed care plans with the FQHC look alikes NPI and Tax Id. Considering we only provided sensitive services before, are we now required to provide whole primary care visits? I know that the family planning visits will qualify as a face to face encounter for FQHC billing, but what if the patient has a sore throat, too? And wants to come back for a visit to check that out? Can we refer them to a different provider for that and only still provide them with their family planning services?
We are in San Francisco and are located in a two plan managed care model in the city. One of which is SFHP and we are a medical home for them and provide the clients within our medical home all of their care, with no limit on what they are being seen for.
The other plan is Anthem Managed Medi-Cal. We currently are not in network, but the new NPI and TAX ID we will be billing with is in network and sees these clients for all of their care. Are we now required to do the same? I can’t wrap my head around how we can deny primary care services as an FQHC to someone, regardless of who their medical home is.
Any and all FQHC information would be greatly appreciated.
Thank you in advance!!
-Angela
Medical Billing and Coding Forum
