Choosing an RCM partner for an FQHC is a high-stakes decision. The wrong partner — even a competent general medical billing company — can leave significant revenue uncollected and create compliance exposure. Here is the evaluation framework:
Non-negotiable FQHC-specific expertise:
- Does the vendor understand the FQHC PPS model for both Medicare and Medicaid? Can they explain qualifying encounter requirements without prompting?
- Have they worked with FQHCs in your state? State Medicaid FQHC rules vary significantly — a vendor who knows Medicare FQHC billing but not your state’s Medicaid program is only half-equipped.
- Do they have experience with Medicare cost report preparation and reconciliation? This is a specialized function that not all billing companies offer.
- Do they understand HRSA compliance requirements — sliding fee scale documentation, UDS reporting, site visit preparation?
Operational requirements:
- Experience with your EHR and billing platform (eClinicalWorks, NextGen, athenahealth, Epic, and others are common in FQHCs)
- A defined process for same-day visit review — ensuring qualifying encounters are correctly identified and coded
- Denial management experience with both Medicare Administrative Contractors (MACs) and state Medicaid programs
Performance accountability:
- Request FQHC-specific performance data: qualifying visit rate, FQHC PPS denial rate, Medicaid encounter data rejection rate
- Ask for references from FQHCs of similar size, payer mix, and service scope
- Ensure the vendor tracks and reports performance at the encounter level — not just aggregate collections
Squadyen’s FQHC billing team has deep experience with PPS billing, state Medicaid encounter submission, and HRSA compliance requirements. We support FQHCs from day-to-day billing through cost report coordination.