What We Do
- PPS Reimbursement Integrity
- Compliance & Revenue Accountability
Structured Billing Oversight for FQHCs
Federally Qualified Health Centers operate within a distinct reimbursement environment shaped by the Prospective Payment System (PPS), federal compliance standards, sliding fee scale policies, and diverse payer participation. Maintaining accuracy across encounters while meeting reporting and funding requirements demands disciplined operational control.
Our approach aligns encounter validation, documentation accuracy, coding integrity, and claims submission within a structured billing framework. We focus on protecting PPS reimbursement, minimizing payment discrepancies, and ensuring alignment with regulatory expectations.
Through defined oversight mechanisms, denial intelligence, and performance monitoring, we help FQHCs strengthen financial accountability while supporting their mission-driven care delivery.
FQHC Billing Framework
FQHC billing requires a disciplined framework aligned to Prospective Payment System (PPS) guidelines, federal compliance standards, and multi-payer coordination. Variations in encounter documentation, coding accuracy, and eligibility validation can directly impact reimbursement integrity and reporting accuracy.
Our structured framework integrates patient access, encounter validation, coding oversight, claims submission, and denial management into a coordinated operating model. By reinforcing process controls and accountability checkpoints, we help FQHCs reduce payment discrepancies, strengthen compliance alignment, and maintain financial stability in support of community-based care.
Encounter Validation & Eligibility Controls
Accurate insurance verification, sliding fee scale alignment, and encounter qualification checks to protect PPS reimbursement eligibility.
Documentation & Coding Integrity
Review of encounter documentation and coding alignment to ensure compliance with federal billing standards and accurate claim submission.
PPS Claim Submission Oversight
Structured claim processing aligned to PPS billing rules to minimize payment variances and processing delays.
Denial Intelligence & Revenue Protection
Trend analysis and revenue leakage identification supported by Root Cause Analysis (RCA) and targeted Corrective & Preventive Action (CAPA) measures.
PPS Reimbursement Integrity
Encounter Accuracy Controls
Regulatory Compliance Alignment
Revenue Accountability Oversight
Denial Intelligence Insights
Financial Stability Assurance
What are the most common billing mistakes that cost FQHCs reimbursement?
The six most impactful: billing non-qualifying encounters as PPS visits, incorrect same-day visit consolidation, missing or mismatched G-codes, inadequate sliding fee scale documentation, failure to capture all billable same-day services, and cost report errors that permanently affect the PPS rate for future years.
Does Squadyen have experience with both Medicare and Medicaid FQHC billing?
Yes. Medicare and Medicaid FQHC reimbursement operate under different rules, and state Medicaid FQHC methodologies vary significantly. Our team is experienced with both Medicare PPS billing and state-specific Medicaid encounter data submission requirements — including the dual submission processes that many state programs require.
How does sliding fee scale billing work and what are the compliance risks?
FQHCs must offer sliding fee discounts to patients at or below 200% of the Federal Poverty Level — a Board-approved, HRSA-required policy. Billing compliance means applying the discount accurately after insurance, documenting income verification annually, and categorising sliding fee write-offs separately from bad debt for accurate cost reporting. Inconsistent application is one of the most common findings in HRSA site visit reviews.