Priority Management Group – CHC Billing Experts

As most of you are aware, Medicare postponed implementation of edits to deny claims when/if the ordering/referring provider is either not enrolled in Medicare and/or does not have a current PECOS record.  There were a great many questions as to why this was required for FQHC providers as they are reimbursed at the all-inclusive rate and do not require individual provider enrollment applications.

CMS has now published guidance for those providers that ‘infrequently receive reimbursement from the Medicare program.’  One of the specific provider types mentioned is those employed at an FQHC.   They have abbreviated the application process but it indicates that it must be completed on paper and include a letter to advise that it is for the sole purpose of ordering/referring services for Medicare beneficiaries and CANNOT be reimbursed for services performed. 

While it sounds like they were being sensitive to the facts, it does not eliminate the need to complete the full 855I and R to capture payment for any services that are carved out of the FQHC Medicare contract. 

Here is the link and there are a few included in the document that you may want to check out.  I haven’t read through them all but will do so.  I also haven’t seen when the edit will be put into place as a final rule but we need to get ahead of the curve, just in case.

http://www3.cms.gov/MedicareProviderSupEnroll/Downloads/SpecialEnrollmentFactsheetInfrequentPhysicianReimbursement.pdf

By: Kristie Sell Viveiros, CPC, VP of Billing Operations Priority Management Group, Inc

By Robert Skeffington, Partner, PMG, Inc.

Now that the celebrations have ended and the confetti has been cleared, it’s time to consider how the Patient Protection and Affordable Care Act will impact Federally Qualified Health Centers (FQHCs).

As one of the most effective federal programs, FQHCs are poised to continue their prominence. Nearly everyone agrees that covering more individuals with health insurance is a positive step forward, as is substantially growing the FQHC program. But what, if anything, will change in the revenue and/or billing process as a result of the new law? Patient revenues from Medicaid, Medicare and other payers make up more than 50 percent of an FQHC’s revenue. As such, this question requires further examination.But what, if anything, will change in the revenue and/or billing process as a result of the new law? Billing is more than half of the average FQHC’s annual revenue, so this question requires a closer look.

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Pawtucket, R.I., May 19, 2010 — Priority Management Group, Inc. (PMG), a leading national supplier of revenue cycle management and consulting services to community health centers, announced today it has entered into an agreement to serve East Liberty Family Health Care (ELFHC) of Pittsburgh, Penn.

The contractual arrangement calls for PMG to deliver a comprehensive suite of services in the back-end billing staffing, denial management and clearinghouse areas. PMG also will provide consulting services, including a full onsite operational assessment, to improve the effectiveness and efficiency of front-end billing processes along with semi-annual in-service training sessions to ensure appropriate coding by physicians.

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Pawtucket, RI and Washington, NC – May 22, 2007

PMG, the leading supplier of outsourced billing services for Federally Qualified Community Health Centers announced today that Metropolitan Health Centers entered into an agreement to provide medical and dental billing services.

Metropolitan is a 330-funded Community Health Center located at the heart of North Carolina’s Inner Banks in Washington, NC. The organization was incorporated in 1999 and provides healthcare to individuals regardless of their age, race or faith or ability to pay. The organization serves the health care needs of patients in Beaufort, Hyde, Pamlico and Martin Counties. The corporation recently celebrated the opening of its newest clinic offering family centered primary care medicine, diagnostic imaging, pharmaceutical and dental services to answer the needs of its rapidly expanding patient base. Metropolitan also provides chronic disease case management and outreach services to the regions Diabetic and HIV patients through grants from the State Office of Minority Health.

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