Healthcare organizations are focused on year-over-year growth, and this usually means adding new programs and services. But it doesn’t always have to.  Sometimes the strongest financial improvements come from tightening up what you’re already doing. 

For Federally Qualified Health Centers operating on tight margins, launching new programs or adding service lines isn’t always realistic. Your staff is already stretched thin, grant funding cycles don’t always align with when you need capital for growth, and adding a new program on top of an already stacked deck of services can sometimes create unnecessary complexity without creating significant community impact.  

But new services are not the only way to grow! Many FQHCs are leaving revenue on the table in their existing workflows. Not because you’re doing anything wrong, but because the billing model you work within (Prospective Payment System, sliding fee discounts, wraparound payments, multiple payer types) creates natural gaps where revenue quietly slips through. 

Let’s look at where those gaps typically show up and what high-performing health centers do differently. 

The Encounter Documentation Gap 

Under PPS billing, you receive a fixed rate per qualifying encounter regardless of how many services you provide during that visit. This makes every encounter valuable, but it also means that if a visit doesn’t meet the specific criteria for a billable encounter, you lose the entire payment (not just a portion of it). 

What makes an encounter billable? It needs to include a medically necessary service, be provided by a qualified provider (physician, nurse practitioner, physician assistant, licensed clinical social worker, clinical psychologist, or certified nurse midwife), involve face-to-face interaction (in most cases), be comprehensive enough to count as the primary visit for the day, and be properly documented. 

The challenge shows up when documentation is incomplete. A provider sees the patient, delivers excellent care, but the note doesn’t clearly establish medical necessity or doesn’t document the face-to-face component. When the billing team reviews the encounter, they can’t submit it because required elements are missing. 

What works better: Brief monthly training sessions where clinical staff review what qualifies as a PPS-eligible encounter. When providers understand that specific documentation elements trigger payment (not just good clinical notes), accuracy improves without adding administrative burden. Consider creating a simple checklist that outlines the must-have components and share examples of complete versus incomplete encounter documentation. 

Same-Day Encounter Optimization 

PPS rules generally do not allow for multiple billable encounters on the same day, but there are a few exceptions. For example, if a patient has a medical visit and a behavioral health visit on the same day it can generate two separate PPS payments, as long as each encounter is properly documented with distinct providers and separate notes. 

Many health centers miss this opportunity because front desk staff aren’t trained on same-day scheduling optimization or because clinical teams don’t realize that combining visits in one note collapses two billable encounters into one payment. 

What works better: Train scheduling staff to spot these exceptions and to schedule those appointments appropriately. Make sure clinical teams understand that separate encounters require separate documentation, even when they occur on the same day. A simple workflow adjustment (ensuring each qualifying visit has its own distinct note with the appropriate provider signature) can significantly increase your encounter count without adding patient volume. 

Wraparound Payment Reconciliation 

For FQHCs billing Medicaid managed care, wraparound payments bridge the gap between what the MCO pays and your full PPS rate. If your PPS rate is $180 and an MCO pays you $120 for an encounter, the state owes you a $60 wraparound payment to make up the difference. 

The problem is that wraparound reconciliation often happens quarterly, involves manual tracking of which encounters were paid by which MCO at what rate, and requires submitting documentation to the state for supplemental payment. If your team doesn’t have a systematic way to track this, wraparound payments get missed entirely or submitted late (creating cash flow gaps even when you eventually receive the payment). 

What works better: Establish a regular reconciliation schedule (monthly is ideal, quarterly at minimum) where you’re comparing MCO payments to your PPS rate and identifying the gap. Document which encounters are owed wraparound payments and submit that documentation to the state within the filing window. Some health centers assign one staff member to own this process rather than spreading it across multiple people, which reduces the chance of payments falling through the cracks. 

Sliding Fee Scale Verification Delays 

FQHCs are required to offer sliding fee discounts based on verified patient income and household size. This is a core part of FQHC operations, but it can also create a billing workflow challenge. 

When income verification is incomplete or delayed, billing gets held up. You can’t finalize the patient’s discount level, which means you can’t determine their responsibility, which means the encounter sits unbilled while you wait for documentation. If verification takes weeks (or if it never gets completed), you’re carrying unbilled encounters that age while staff chases paperwork. 

What works better: Set a clear timeline for when income verification must be completed and establish who is responsible for follow-up when documentation is missing. Making sure that one or more staff members know that they are the owners of these processes will help them get addressed in a timely manner. Some health centers implement a “temporary discount” policy where patients are assigned a standard discount level at registration, allowing billing to proceed, with adjustments made once full verification is received. Others dedicate specific staff time each week to completing outstanding verifications rather than waiting for patients to bring documents back on their own. Finding a system that works for you will help you collect the correct revenue from patient payments. 

Small Workflow Adjustments Create Real Impact 

Targeted improvements to specific parts of your existing operation that are causing revenue leakage can create big impact and ultimately, growth! 

The reason they work is because they address root causes rather than symptoms. Training clinical staff on encounter documentation requirements prevents unbillable visits before they happen (rather than catching them after the fact when it’s too late to fix). Optimizing same-day scheduling captures revenue you’re already generating but not billing for. Implementing a specific process for wraparound reconciliation ensures you collect payments you’re entitled to but might be missing. 

Even small percentage improvements in encounter capture or payment reconciliation translate to meaningful revenue when applied across your entire patient population. And because these adjustments strengthen existing workflows rather than adding new complexity, they’re sustainable without increasing staff workload or operational costs. 

Moving Forward 

Strengthening revenue doesn’t have to mean doing more. Sometimes it means doing what you’re already doing more consistently, more accurately, and more completely. 

If your team is stretched thin managing the complexity of PPS billing, wraparound reconciliation, and encounter documentation requirements, you’re not alone. Many health centers find that working with revenue cycle partners who specialize in FQHC billing provides the expertise and systematic processes needed to capture revenue that might otherwise slip through the gaps. 

Whether you choose to optimize workflows internally or bring in external support, the opportunity is there. Your team is already delivering the care. Making sure you’re capturing the revenue for that care is simply a matter of tightening the workflows that connect clinical delivery to billing submission. 

Practice Management has worked with FQHCs since 2011, supporting health centers with full revenue cycle management services and targeted consulting to identify and address revenue leakage. If you’re looking to grow without adding service lines, we’re here to help. 

Tag: revenue cycle management

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Title

As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
Continue Readiing
image

Title

As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
Continue Readiing

How FQHCs Can Strengthen Revenue Without Adding Services 

Posted on by Carolyn Yoder

Healthcare organizations are focused on year-over-year growth, and this usually means adding new programs and services. But it doesn’t always have to.  Sometimes the strongest financial improvements come from tightening up what you’re already doing. 

For Federally Qualified Health Centers operating on tight margins, launching new programs or adding service lines isn’t always realistic. Your staff is already stretched thin, grant funding cycles don’t always align with when you need capital for growth, and adding a new program on top of an already stacked deck of services can sometimes create unnecessary complexity without creating significant community impact.  

But new services are not the only way to grow! Many FQHCs are leaving revenue on the table in their existing workflows. Not because you’re doing anything wrong, but because the billing model you work within (Prospective Payment System, sliding fee discounts, wraparound payments, multiple payer types) creates natural gaps where revenue quietly slips through. 

Let’s look at where those gaps typically show up and what high-performing health centers do differently. 

The Encounter Documentation Gap 

Under PPS billing, you receive a fixed rate per qualifying encounter regardless of how many services you provide during that visit. This makes every encounter valuable, but it also means that if a visit doesn’t meet the specific criteria for a billable encounter, you lose the entire payment (not just a portion of it). 

What makes an encounter billable? It needs to include a medically necessary service, be provided by a qualified provider (physician, nurse practitioner, physician assistant, licensed clinical social worker, clinical psychologist, or certified nurse midwife), involve face-to-face interaction (in most cases), be comprehensive enough to count as the primary visit for the day, and be properly documented. 

The challenge shows up when documentation is incomplete. A provider sees the patient, delivers excellent care, but the note doesn’t clearly establish medical necessity or doesn’t document the face-to-face component. When the billing team reviews the encounter, they can’t submit it because required elements are missing. 

What works better: Brief monthly training sessions where clinical staff review what qualifies as a PPS-eligible encounter. When providers understand that specific documentation elements trigger payment (not just good clinical notes), accuracy improves without adding administrative burden. Consider creating a simple checklist that outlines the must-have components and share examples of complete versus incomplete encounter documentation. 

Same-Day Encounter Optimization 

PPS rules generally do not allow for multiple billable encounters on the same day, but there are a few exceptions. For example, if a patient has a medical visit and a behavioral health visit on the same day it can generate two separate PPS payments, as long as each encounter is properly documented with distinct providers and separate notes. 

Many health centers miss this opportunity because front desk staff aren’t trained on same-day scheduling optimization or because clinical teams don’t realize that combining visits in one note collapses two billable encounters into one payment. 

What works better: Train scheduling staff to spot these exceptions and to schedule those appointments appropriately. Make sure clinical teams understand that separate encounters require separate documentation, even when they occur on the same day. A simple workflow adjustment (ensuring each qualifying visit has its own distinct note with the appropriate provider signature) can significantly increase your encounter count without adding patient volume. 

Wraparound Payment Reconciliation 

For FQHCs billing Medicaid managed care, wraparound payments bridge the gap between what the MCO pays and your full PPS rate. If your PPS rate is $180 and an MCO pays you $120 for an encounter, the state owes you a $60 wraparound payment to make up the difference. 

The problem is that wraparound reconciliation often happens quarterly, involves manual tracking of which encounters were paid by which MCO at what rate, and requires submitting documentation to the state for supplemental payment. If your team doesn’t have a systematic way to track this, wraparound payments get missed entirely or submitted late (creating cash flow gaps even when you eventually receive the payment). 

What works better: Establish a regular reconciliation schedule (monthly is ideal, quarterly at minimum) where you’re comparing MCO payments to your PPS rate and identifying the gap. Document which encounters are owed wraparound payments and submit that documentation to the state within the filing window. Some health centers assign one staff member to own this process rather than spreading it across multiple people, which reduces the chance of payments falling through the cracks. 

Sliding Fee Scale Verification Delays 

FQHCs are required to offer sliding fee discounts based on verified patient income and household size. This is a core part of FQHC operations, but it can also create a billing workflow challenge. 

When income verification is incomplete or delayed, billing gets held up. You can’t finalize the patient’s discount level, which means you can’t determine their responsibility, which means the encounter sits unbilled while you wait for documentation. If verification takes weeks (or if it never gets completed), you’re carrying unbilled encounters that age while staff chases paperwork. 

What works better: Set a clear timeline for when income verification must be completed and establish who is responsible for follow-up when documentation is missing. Making sure that one or more staff members know that they are the owners of these processes will help them get addressed in a timely manner. Some health centers implement a “temporary discount” policy where patients are assigned a standard discount level at registration, allowing billing to proceed, with adjustments made once full verification is received. Others dedicate specific staff time each week to completing outstanding verifications rather than waiting for patients to bring documents back on their own. Finding a system that works for you will help you collect the correct revenue from patient payments. 

Small Workflow Adjustments Create Real Impact 

Targeted improvements to specific parts of your existing operation that are causing revenue leakage can create big impact and ultimately, growth! 

The reason they work is because they address root causes rather than symptoms. Training clinical staff on encounter documentation requirements prevents unbillable visits before they happen (rather than catching them after the fact when it’s too late to fix). Optimizing same-day scheduling captures revenue you’re already generating but not billing for. Implementing a specific process for wraparound reconciliation ensures you collect payments you’re entitled to but might be missing. 

Even small percentage improvements in encounter capture or payment reconciliation translate to meaningful revenue when applied across your entire patient population. And because these adjustments strengthen existing workflows rather than adding new complexity, they’re sustainable without increasing staff workload or operational costs. 

Moving Forward 

Strengthening revenue doesn’t have to mean doing more. Sometimes it means doing what you’re already doing more consistently, more accurately, and more completely. 

If your team is stretched thin managing the complexity of PPS billing, wraparound reconciliation, and encounter documentation requirements, you’re not alone. Many health centers find that working with revenue cycle partners who specialize in FQHC billing provides the expertise and systematic processes needed to capture revenue that might otherwise slip through the gaps. 

Whether you choose to optimize workflows internally or bring in external support, the opportunity is there. Your team is already delivering the care. Making sure you’re capturing the revenue for that care is simply a matter of tightening the workflows that connect clinical delivery to billing submission. 

Practice Management has worked with FQHCs since 2011, supporting health centers with full revenue cycle management services and targeted consulting to identify and address revenue leakage. If you’re looking to grow without adding service lines, we’re here to help. 

image

Title

As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
Continue Readiing
image

Title

As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
Continue Readiing

Your Revenue Is Aging While You Wait 

Posted on by Carolyn Yoder

You open your accounts receivable aging report and see $250,000 in the 90+ day bucket. These claims were billed months ago. They’re technically still collectible. So why does that number matter so much? 

Because by the time a claim reaches 90 days, you’ve often missed your best opportunities to resolve it efficiently. The payers who were responsive at 30 days may not remember the claim at 90. The documentation that was easy to locate in week two is buried by month three. And those timely filing deadlines? Some of them have already passed. 

The most expensive billing problems are often the ones that age quietly in the background while your team focuses on newer work. Let’s talk about why earlier intervention matters and what that can look like in practice. 

Why Claims Age Faster Than You Think 

Claims don’t age because billing teams forget about them. They age because small issues go unnoticed until they become bigger problems. 

Here’s the pattern we see playing out over and over again: A claim gets submitted with a minor coding error and is denied at 15 days. Your team doesn’t catch the denial notification for another week. By the time someone investigates, corrects the code, and resubmits, the claim is at 35 days. If that resubmission has another issue (maybe a missing modifier this time), you’re suddenly at 60 days before anyone realizes the claim still hasn’t paid. 

Reworking a denied claim costs providers an average of $25 and can get as high as $118, and that doesn’t even factor in the revenue delay. When this pattern repeats across dozens of claims, aging AR stops being just a collections issue and starts being a workflow issue. 

The other common driver for aging AR? Lack of structured follow-up. Without a system that triggers action at specific intervals, claims can slip from 30 to 60 to 90 days without a single touchpoint. No one calls the payer. No portal check happens. The claim just sits there, aging. 

What Changes at Each Stage 

The aging buckets on your AR report aren’t arbitrary. They represent meaningful shifts in how hard claims are to collect and how much effort is required to resolve them. 

In the 0 to 30 day range, most claims are still in normal processing timeframes. Many payers process claims within 30 days, so accounts in this bucket are either pending or recently paid. Best-in-class billing operations maintain around 65% or more of total AR here. 

Once claims hit 31 to 60 days, intervention becomes more valuable. A claim sitting at 45 days isn’t necessarily denied. It might be pending additional review, stuck in a payer queue, or waiting on documentation your team didn’t realize was requested. A quick portal check or phone call at this stage often reveals the issue and gives you time to resolve it. 

By 61 to 90 days, you’re working against timely filing deadlines. Many commercial payers enforce 90-day filing windows, and some are shorter. At this point, anything in this bucket deserves high-priority attention. 

Industry research shows that collectability drops significantly as claims age, which is why the HFMA recommends keeping AR over 90 days below 10% of total receivables. After 90 days, collectability drops significantly. These claims are expensive to work, difficult to resolve, and increasingly at risk of timing out completely. 

What Works: Building Earlier Touchpoints 

The solution to growing AR is not working harder on old claims but instead focusing on catching issues earlier, when they’re still manageable. 

High-performing revenue cycle teams implement structured follow-up at 30 and 60 days, when claims are still fresh and payers are responsive. One effective approach is a regular review cadence: checking claims at 7 days to confirm payer receipt, 17 days to check processing status, and 30 days to escalate if payment hasn’t been received. This rhythm keeps claims in active status rather than passive waiting. 

Segmenting your AR by aging bucket also helps your team prioritize. Claims in the 61 to 90 day range typically need more attention than those in the 0 to 30 day range, and anything approaching a filing deadline should be flagged immediately. 

Clean claim submission matters just as much as follow-up. The more claims you can get paid on first submission, the fewer end up aging. Real-time eligibility verification, pre-submission claim scrubbing, and accurate coding all reduce denials, which directly reduces the volume of claims that need rework. 

Weekly AR aging reviews can make a big difference too. When leadership reviews aging reports weekly instead of monthly, problems surface faster and teams can course-correct before small issues become patterns. 

Why This Matters More for FQHCs 

Federally Qualified Health Centers often face additional pressure around AR aging. Many FQHCs operate on thin margins (on average around 2.9%), which means even modest delays in collections can create operational strain. 

The payer mix at most FQHCs includes high percentages of Medicaid, Medicare, and uninsured patients. Each requires different follow-up approaches and different timely filing rules. Medicaid managed care plans, in particular, often have shorter filing windows than traditional Medicaid, and missing those deadlines means losing revenue your health center has already earned. 

Grant funding cycles also make cash flow management more complex. Section 330 grants provide critical support, but they don’t replace the need for strong patient service revenue. When AR ages and cash flow tightens, health centers may find themselves unable to cover operational expenses between grant disbursements, even when their overall financial position looks stable on paper. 

For FQHC leadership, monitoring AR aging isn’t just about collections performance. It’s about organizational sustainability. Best practice for health center liquidity is a minimum of 90 days cash on hand, and high AR aging directly impacts your ability to maintain that cushion. 

Moving Forward 

Reducing aging AR doesn’t require a complete overhaul – just consistent habits applied at the right intervals. 

Start by reviewing your current AR aging distribution. If more than 20% of your total AR is sitting in buckets older than 60 days, earlier intervention could help. Look at what’s causing claims to age. Are denials going unnoticed? Is follow-up happening too late? Are coding errors creating rework cycles that add weeks to resolution time? 

Then build a follow-up rhythm that fits your team’s capacity. If you can’t implement a detailed cadence immediately, that’s okay! Start simple and add more touchpoints as your team adjusts. Consistency matters more than complexity. 

The 90-day mark isn’t when AR work begins. It’s where AR work becomes exponentially harder. By shifting your focus to earlier intervention, you can protect revenue before it becomes at risk, reduce the cost of collections, and build a revenue cycle that works proactively. 

If your organization needs support building more effective follow-up workflows or strengthening your revenue cycle processes, our team at Practice Management would love to talk. 

image

Title

As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
Continue Readiing
image

Title

As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
Continue Readiing

Monthly EHR Reports That Protect Revenue 

Posted on by Carolyn Yoder

Your EHR system contains the data you need to catch revenue leaks before they become financial problems. But most healthcare organizations only pull reports sporadically, review them reactively, and miss the patterns that signal where revenue is slipping through the cracks. 

Monthly reporting rhythms create accountability, reveal trends, and give leadership the visibility needed to make informed decisions. Let’s dive into some of the monthly reports great RCM teams should be running regularly, and why that data matters! 

Why Monthly Matters 

According to MGMA data, charge capture failures cost the average multi-provider practice between 1% and 5% of potential revenue. For a practice generating $3 million annually, that’s $30,000 to $150,000 in services rendered but never billed. 

These failures accumulate gradually, and without regular reporting, small gaps compound into significant revenue loss before anyone notices. Monthly reviews help you create a baseline for your organization – after all, you can’t spot trends if you’re only looking at data occasionally. 

Quick disclaimer: We won’t be listing all the specific reports for all the popular EHRs – software is constantly updating, and different specialties prefer different systems. Instead, we will describe the reports, the data they contain, and offer some of the most commonly used report names. Once you know what kind of data you’re looking for, finding (or building) that report in your own system becomes possible! Looking for custom reporting? Check out our billing department assessment services. 

The Core Reports Every Organization Needs 

Charge Reconciliation Report 

This report compares your schedule or appointment log to charges posted. Ideally, charges should be reconciled daily, or at least weekly, but a monthly review of your reconciliation patterns is an absolute must.  Look for departments or providers who consistently show gaps between appointments and posted charges. 

Most EHR systems can generate this by comparing scheduling data to billing data. Look for report names like “charge capture review,” “encounter reconciliation,” or “schedule vs. charges.” 

Aging Accounts Receivable Report 

This shows how long claims have been waiting for payment, broken down by time periods. Anything between a 30 and 45 day average in AR means claims are moving. More than 90 days is a red flag. 

Pull this monthly and look at trends. Is your 90+ day bucket growing? Are specific payers consistently in older buckets? Breaking down AR aging by payer, provider, or service type helps you understand where your team is struggling the most and allows you to focus follow-up efforts where they’ll have the biggest impact. 

Denial Report by Reason 

This categorizes claim denials by payer-provided reason: missing information, authorization required, timely filing, coding errors, eligibility issues. 

The value in this report is pattern recognition. Repeated denials for “missing prior authorization” signal a workflow problem. “Coding errors” for a particular CPT code indicate a training need. Review these reasons monthly and focus on your top three denial reasons by volume or dollar amount. Armed with this knowledge, your training will be laser-focused on the issues that are impacting your revenue right now. 

Clean Claim Rate Report 

Industry benchmark for this stat is above 96% which means 96% or more of your claims should be paid on first submission without edits or appeals. 

If you notice a declining clean claim rate, it could indicate one or more upstream problems: registration data accuracy, coding quality, or charge entry completeness. If your rate drops below benchmark (or is not quite at the national benchmark yet), remember this statistic doesn’t live in a vacuum! Pull your denial report to identify what’s causing rejections. When you start examining how your reports work together, you begin to paint a full picture of your revenue cycle management. 

Days Not Final Coded (DNFC) and Days Not Final Billed (DNFB) Report 

Ideally, coding should happen withing a few days of service and billing should follow immediately. The DNFC and DNFB reports show you which accounts are sitting in limbo – services have been provided but coding has not been finalized, or coding is done but billing is stalled. 

High DNFC indicates coding backlogs and high DNFB points to billing bottlenecks. Reviewing these reports monthly helps you keep your revenue cycle moving. 

How to Use These Reports Effectively 

Set Baselines First 

If you have never pulled a report before, your first few months establish your baseline. Don’t expect perfection right away – your goal is understanding where you are today so you can measure whether your future changes are working. 

Focus on Trends 

One month of elevated denials might be a fluke. Three consecutive months is a trend demanding attention. Monthly reporting reveals patterns invisible in quarterly reviews. 

Assign Ownership and Close the Loop 

Someone needs to own each report. Charge reconciliation might belong to your billing manager. AR aging to your collections lead. Giving each report and its follow up some clear ownership builds in accountability which means your reports regularly get reviewed and improvements get implemented. 

When you’re reviewing your data, make sure to share findings with teams who can fix them. If denial reports show eligibility issues, that’s a registration training need not a provider training issue. Monthly cross-functional check-ins keep everyone aligned, and communication channels opened. 

When to Bring in Outside Support 

Many healthcare organizations find that building consistent reporting rhythms and knowing what to do with the data is a consistent struggle. It’s not that the reports don’t exist; it’s that internal teams either don’t have time to analyze them thoughtfully or don’t have the expertise to interpret what story the numbers are telling. 

This is where outsourcing revenue cycle management services can provide value that goes beyond just processing claims. When you work with an expert RCM team, they’re pulling these reports regularly, spotting patterns across your organization, and bringing their insights about what’s normal versus what indicates a problem worth investigating directly to your leadership. 

An experienced RCM company can help you understand which metrics to prioritize for your specific payer mix, specialty, and patient population. They can benchmark your performance against similar organizations and identify opportunities you might not see when you’re focused on daily operations. If that sounds like something your organization needs (even if it’s just for one of your programs or services) we’d love to connect! 

Building the Habit 

Start simple. Pick three reports from this list and commit to reviewing them on the same day each month. First Monday of the month, last Friday, whatever works for your schedule – as long as it is consistent. 

Block 30 minutes on your calendar, pull the reports, note any significant changes from last month, and identify one action item to address. Don’t try to fix everything at once. Focus on the highest-impact opportunity each month and start there. 

As the rhythm becomes routine, you can expand to additional reports or deeper analysis. Your goal with great reporting is to build visibility. When you know where your revenue leaks are, you can plug them. By monitoring trends consistently, your team can address small problems before they become big financial losses. 

Your EHR might already have most of these reports built in, and learning how to run them and read them regularly arms you with the knowledge you need to protect your revenue. Monthly reporting turns your data into actionable intelligence that keeps your revenue cycle healthy and your organization financially stable. 

image

Title

As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
Continue Readiing
image

Title

As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
Continue Readiing

How Payer Policy Changes Quietly Impact FQHC Revenue (And What to Do About It) 

Posted on by Carolyn Yoder

Payer policy changes don’t usually make a grand entrance. Changes slip into Medicaid provider manuals, get buried in managed care organization updates, or appear as subtle shifts in how your PPS encounter claims are being adjudicated. 

By the time most healthcare organizations realize a policy has changed, they’ve already lost revenue. 

For community health centers, this challenge is amplified. You’re navigating state Medicaid programs, multiple Medicaid managed care plans, Medicare, and grant requirements, each with different update schedules and notification methods. Staying current requires intentional systems designed for your unique payer complexity. 

Recent Policy Changes That Caught FQHCs Off Guard 

Medicare Prior Authorization Pilot Begins 

Starting January 1, 2026, a pilot program launched where traditional Medicare began requiring prior authorization for 17 specific outpatient services in six states (Arizona, New Jersey, Ohio, Oklahoma, Texas, and Washington). For FQHCs serving Medicare beneficiaries in these states, this represents a major workflow change. Organizations had to quickly implement new authorization processes for services they’d been billing routinely for years. 

Shortened Prior Authorization Timelines Across All Payers 

CMS implemented new rules for 2026 requiring Medicare Advantage, Medicaid, and CHIP programs to issue prior authorization decisions within 72 hours for expedited requests and 7 calendar days for standard requests. This significantly shortens previous timelines. For FQHCs managing authorization workflows for multiple Medicaid managed care organizations (MCOs), this means tighter submission deadlines and faster follow-up requirements. 

State Medicaid MCO Policy Variations 

Many states continue transitioning more Medicaid beneficiaries into managed care organizations (MCOs), and these plans often have different prior authorization requirements than traditional Medicaid. The challenge for FQHCs? Each MCO in your service area may have different requirements, creating a complex web of policies to track, and those policies can change multiple times per year. 

Why Policy Changes Hit FQHCs Harder 

PPS Creates Hidden Impact 

Under Prospective Payment System billing, you receive a set encounter rate regardless of specific services provided. This can mask policy change impacts initially. If a service suddenly requires prior authorization but you’re still getting your PPS rate, you might not notice until a post-payment review demands refunds for encounters that didn’t meet new requirements. 

Limited Billing Staff Capacity 

Many FQHCs operate with lean billing teams already managing high volumes across multiple complex payers. Adding “monitor all payer policy updates” to their workload isn’t realistic without dedicated resources or systems. 

Grant Funding Adds Complexity 

HRSA requirements, state program rules, and grant-funded service requirements create additional compliance layers that interact with payer policies in ways that aren’t always obvious. A payer policy change affecting a grant-tied service can impact both revenue and compliance reporting. 

Building Proactive Monitoring Systems 

Designate Ownership by Payer Type 

If you have multiple billing staff, consider assigning payer monitoring responsibilities by category: one person owns Medicaid/MCO updates, another tracks Medicare and commercial payers. This distributes the workload and creates clear accountability. 

Leverage State and National FQHC Associations 

Your state Primary Care Association and the National Association of Community Health Centers often monitor and communicate major policy changes affecting FQHCs. Make sure someone on your team is actively engaged with these resources, not just passively receiving newsletters. 

Track MCO-Specific Policies Separately 

Create a simple matrix showing which MCOs operate in your service area and what their key policy differences are (prior authorization requirements, covered services, documentation expectations). Update this quarterly as you learn about changes. 

Connect Policy Monitoring to Encounter Reporting 

Since FQHC billing is encounter-based, policy changes often affect whether specific visits qualify as billable encounters. Your policy monitoring should feed directly into encounter validation processes. If a payer changes what constitutes a qualifying visit, your encounter submission workflows need to adjust immediately. 

Revenue cycle management services that specialize in FQHCs understand PPS complexities and often include payer policy monitoring as part of their standard offering. They’re tracking changes across the health centers they serve, which provides early warning about shifts affecting the FQHC sector broadly. 

When You Discover a Change After It’s Already Happened 

Assess Encounter-Level Impact 

Run a report showing encounters submitted after the policy change date. For FQHCs, this matters differently than for fee-for-service providers. An invalid encounter doesn’t just mean one denied service – it means an entire visit that may need to be resubmitted differently or written off entirely. 

Review Your Sliding Fee Discount Impact 

If a policy change affects how you’re billing patients on your sliding fee scale, you may have billing integrity issues that go beyond payer revenue. Make sure patient responsibility amounts are still calculated correctly under the new policy. 

Implement Corrections Immediately 

Update your encounter submission protocols, inform clinical staff about any documentation changes needed, and adjust your scheduling or authorization workflows. After you have a solid foundation in place for any new policies, you can begin to address the backlog of affected encounters. 

Consider an FQHC-Specific Coding Audit 

General coding audits don’t always catch FQHC-specific issues related to encounter billing and PPS requirements. A coding audit by an outside team with FQHC expertise can identify whether you’re missing revenue opportunities or creating compliance risks based on how you’re interpreting payer policies in the context of PPS billing. 

The Value of Specialized Support 

Many FQHCs find that working with revenue cycle partners who specialize in community health centers provides policy expertise that’s difficult to maintain internally. These partners understand how Medicaid PPS, Medicare PPS, and managed care requirements intersect. They catch policy changes that would slip past a general billing team. 

Even periodic consulting support, like a billing assessment focused specifically on how recent payer changes have affected your operations, can identify gaps before they become significant revenue loss. The investment often pays for itself in recovered revenue and prevented future denials. 

Staying Ahead 

The FQHCs that maintain financial stability aren’t necessarily the ones with the most resources. They’re the ones who’ve built systems to catch policy changes early, communicate them across clinical and billing teams, adjust workflows before revenue is impacted, and recognize when it’s time to bring in expert outsourced help. 

Whether you’re setting up your first payer monitoring system or refining workflows that have served you for years, the goal is the same: protecting your revenue so you can protect your mission. Payer policies will always change but with the right systems in place, those changes don’t have to catch you off guard or threaten your financial stability. 

If your team could use support identifying where policy changes may have impacted your revenue, or you’d like to strengthen your monitoring systems, we’re here to help. Our revenue cycle services are designed specifically with FQHC complexities in mind, helping you stay ahead of the changes that matter most to your organization. 

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As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
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As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
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Your Revenue Cycle Doesn’t Need an Overhaul (It Needs This Instead) 

Posted on by Carolyn Yoder

When healthcare leaders think about improving their revenue cycle, there’s a natural tendency to think big: new software platforms or entirely new teams. The assumption is often that fixing large revenue cycle problems requires equally large and dramatic solutions. 

Here’s what we’ve learned after decades of working with healthcare organizations nationwide: the biggest financial gains often come from small, targeted adjustments. 

The Problem with “Rip and Replace” 

Major overhauls sound transformative, but they come with real costs: months-long implementation timelines, extensive staff retraining, and disrupted daily operations. There’s no guarantee a new system will solve your specific problems better than fixing systems you already have in place. 

According to the American Medical Association, even small improvements in revenue cycle management can strengthen cash flow. Organizations don’t need to chase every metric at once. Success comes from picking one or two key performance indicators, tracking them consistently, and using focused attention to move the needle. 

Where Small Changes Create Big Impact 

Front-End Accuracy 

The most expensive billing problems are often the ones that start at registration. A missing insurance number, an incorrect date of birth, or an unverified coverage detail creates a domino effect that touches every step that follows. 

Small adjustment: Implement a simple verification checklist at check-in. Train front desk staff to capture three critical data points correctly every single time. This 10-minute workflow change can reduce your denial rate significantly. 

Claim Scrubbing Before Submission 

Most organizations submit claims and deal with errors only after they’re denied. This creates unnecessary delays and rework for both billing and clinical teams. 

Small adjustment: Add a review step between coding and submission. A structured billing assessment can identify which claim types are most likely to have errors, letting you focus quality checks on high-risk categories rather than manually reviewing everything. 

Days in Accounts Receivable 

Anything between 30 and 45 days in AR means claims are moving and reimbursement is timely. More than 90 days is a red flag. Yet many organizations only look at this number quarterly, and by then the damage is already done. 

Small adjustment: Schedule weekly 15-minute check-ins focused solely on AR aging. When your leadership understands what those numbers mean, they start asking better questions and connecting daily operations with financial outcomes. 

Denial Pattern Recognition 

Most billing teams address denials reactively, one claim at a time. This keeps them busy but doesn’t stop the same problems from recurring. 

Small adjustment: Spend one hour monthly reviewing denial reasons by category. If you’re seeing repeated denials for the same service or payer, that’s a signal that something upstream needs attention. One coding audit focused on your highest-denial CPT codes can reveal patterns you’d never catch just by handling individual claims. 

Special Considerations for FQHCs 

Community health centers face unique revenue cycle complexity that makes small adjustments even more valuable. FQHCs billing includes the Prospective Payment System, where they receive a fixed encounter rate rather than fee-for-service payments. This means every missed or incorrectly documented encounter represents lost revenue that can’t be recovered by simply resubmitting a claim. 

Small adjustments that create outsized impact for FQHCs: 

Encounter Documentation Training: A brief monthly training on what qualifies as a PPS-eligible encounter helps clinical staff self-monitor their documentation. When providers understand that a face-to-face visit must include specific elements, accuracy improves without adding administrative burden. 

Sliding Fee Scale Verification: Income verification delays slow down billing and create compliance risks. Establishing a clear timeline for when verification must be completed, and who’s responsible for follow-up, helps eliminate this common bottleneck. 

State-Specific PPS Rules: Medicaid PPS methodologies vary by state. Understanding whether your state allows Alternative Payment Methodologies can open up flexibility you didn’t know existed. A simple review of current state regulations might reveal opportunities for rate adjustments based on scope of service changes. 

Why This Approach Works 

Small adjustments succeed because they’re specific (addressing one identified problem), measurable (you see results in weeks, not months), sustainable (staff can absorb gradual changes without overwhelm), and cost-effective (optimizing what you have rather than buying something new). Small wins build confidence and reduce resistance to future improvements. 

Getting Started 

The challenge isn’t usually knowing that improvements are needed. Most healthcare leaders can name three revenue cycle problems off the top of their head. The real question is knowing where to start and what will make the biggest difference for your specific situation. 

This is where a focused assessment provides clarity. A billing department review or coding audit doesn’t need to examine every aspect of your operation. It can zero in on your highest-impact opportunities and show you the specific adjustments that will move your organization’s unique metrics. Understanding where you are today makes it possible to choose one high-value change, implement it well, and build from there. 

Small changes, applied consistently to the right problems, create compound results that major overhauls rarely deliver. Sometimes the smartest investment isn’t the biggest one. It’s the most targeted. 

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As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
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Title

As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
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The Documentation Gap: How to Build Better Communication Between Clinical and Billing Teams (Part 2) 

Posted on by Carolyn Yoder

In Part 1, we explored why clinical and billing teams struggle to communicate and what those communication breakdowns actually cost.  

What the numbers say:  

  • Coding mistakes contribute significantly to first-submission denials 

But here’s the good news: improving communication between your teams doesn’t require a complete operational overhaul. It requires intention, consistency, and a few foundational practices. 

Building the Bridge: What Actually Works 

Create shared understanding around documentation expectations 

Clinical teams don’t need to become coding experts, but they do need clarity on what information is critical and why it matters. When providers understand how their documentation directly impacts reimbursement and ultimately, their organization’s ability to sustain services, accuracy improves naturally. 

This is where a structured billing assessment can provide immediate value. By identifying exactly where documentation gaps are occurring and what specific information is missing or unclear, you create a roadmap for targeted improvement rather than vague “document better” directives that can often frustrate your providers even more. 

The key is making expectations specific and accessible. Instead of “document thoroughly,” try “every visit note for this service must include X, Y, and Z to meet payer requirements.” Give providers templates, examples, and clear guidance on what “sufficient documentation” looks like for the services they bill most frequently. 

Establish clear, respectful feedback loops 

When billing teams encounter documentation issues, there should be a defined process for communicating those issues back to clinical leadership. Your billing team should not be chasing down individual providers to give them personal notes on billing issues. Giving your team a pipeline to leadership keeps feedback constructive and systemic rather than feeling like individual criticism. 

The key is making feedback specific and actionable. “Needs better documentation” is not helpful. “The diagnosis doesn’t support the E/M level billed” or “Missing required elements for this CPT code” gives providers something tangible they can fix. 

Consider creating a regular (monthly or quarterly) summary of common documentation issues. Instead of addressing individual claims, look at patterns: “We’re seeing repeated denials for [specific service] because documentation is missing [specific element].” This approach reduces defensiveness and helps clinical leadership identify where targeted training or workflow changes are needed. 

Hold regular touchpoints between clinical and billing leadership 

These don’t need to be long meetings. Brief, recurring check-ins focused on trends and patterns (not individual claims) help shift the conversation from blame to problem-solving. 

Some discussion points we recommend: 

  • What documentation issues are we seeing repeatedly? 
  • What payer requirements have recently changed? 
  • Where are providers getting stuck or confused? 
  • What’s working well that we should reinforce? 

The goal is to create a feedback loop that allows both teams to learn and adjust continuously, rather than discovering problems only when denials pile up. 

Align metrics across teams 

If clinical teams are measured solely on patient volume and billing teams are measured solely on collection rates, you’ve created competing priorities. When both teams share responsibility for “clean claim rate” or “first-pass resolution rate,” you encourage shared accountability. 

Consider tracking metrics like: 

  • First-pass claim acceptance rate 
  • Days to clean claim submission 
  • Documentation query rate 
  • Denial rate by denial reason 

Share these metrics with both teams regularly and celebrate improvements together. This makes it clear: better communication gives everyone a win! 

The Role of Audits and Assessments 

One of the most effective ways to improve communication is to get an objective view of where things are breaking down. This is where coding audits and billing department assessments prove their value. 

A coding audit doesn’t just identify technical coding errors; it reveals patterns in how clinical documentation is (or is not) supporting the services being billed. You might discover that your providers are consistently missing key elements for certain types of visits, or that documentation expectations for a particular payer aren’t being communicated effectively. 

A billing department assessment can highlight where workflows, handoffs, or feedback processes are breaking down between clinical and revenue cycle staff. Sometimes the issue isn’t documentation quality, it’s that billing staff don’t have a clear way to escalate questions or that clinical staff never receive feedback on what they’re doing right. 

The beauty of an outside perspective is that it reduces internal friction. When a third party identifies communication gaps, it’s easier to address them as systems issues rather than personal failures. An objective assessment creates a shared starting point for improvement that both teams can rally around. 

What Better Communication Makes Possible 

When clinical and billing teams are aligned, the benefits show up quickly: 

  • Cleaner claims on first submission 
  • Faster reimbursement and more predictable cash flow 
  • Less time spent on rework and appeals 
  • Improved staff morale on both sides 
  • Clearer visibility into performance for leadership 

Most importantly, better communication allows everyone to focus on what really matters: delivering high-quality care to your community while maintaining the financial health that makes that care sustainable. 

Where to Start 

If you’re ready to improve how your clinical and billing teams work together, start with assessment. Before you can fix communication gaps, you need to understand exactly where they’re occurring and what’s causing them. 

A structured review of your documentation practices, billing workflows, and feedback systems will reveal specific opportunities for improvement. You might find that a few targeted changes (think clearer documentation templates, regular feedback meetings, or updated training on specific payer requirements) create significant momentum. 

The goal isn’t perfection. It’s progress! And progress starts with knowing where you actually are. 

If strengthening the connection between your clinical and billing teams is part of your operational priorities this year, we’d be glad to help you identify where to focus. Our billing assessments and coding audits are designed to give you clarity on what’s working, what’s not, and what specific steps will make the biggest difference for your organization. 

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As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
Continue Readiing
image

Title

As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
Continue Readiing

The Documentation Gap: Why Clinical and Billing Teams Struggle to Connect (Part 1) 

Posted on by Carolyn Yoder

Here’s a scenario playing out in healthcare organizations right now: a provider sees a complex patient, documents the visit thoroughly (or so they think), and moves on to the next appointment. Two weeks later, the billing team submits the claim. Three weeks after that, it gets denied for “insufficient documentation.” 

The provider is frustrated because they think they documented everything. The billing team is frustrated because they can’t bill what isn’t clearly documented. Leadership is frustrated because cash flow is delayed, again. 

Sound familiar? You’re not alone. According to a survey by the AAPC, within any sample of 200 claims, 41% are overcoded and 45% are undercoded, and these coding issues come with real financial repercussions. According to MGMA, the average cost to reprocess a claim in 2021 was $25 – and that number is only increasing. What we see working with healthcare organizations nationwide is that a significant portion of those errors stem from one surprisingly simple problem: clinical and billing teams aren’t speaking the same language. 

The Real Problem Isn’t the People 

This isn’t about inattentive providers or incompetent billing staff – your team cares about your community and your mission. The most common reasons for billing inaccuracy include inadequate clinical documentation supporting the level of billing and a lack of feedback systems designed to correct errors before they become patterns. 

In other words, the problem isn’t the people, it’s the system. Or more accurately, the lack of one. 

Clinical teams are focused on patient care. They’re thinking about diagnoses, treatment plans, connecting with their patients and keeping their community healthy.  

Billing teams are focused on compliance and reimbursement. They’re thinking about codes, payer requirements, ethical billing practices, and documentation specificity.  

Both priorities are valid and necessary to continue to provide amazing care to your communities. The disconnect happens when these two essential functions operate in parallel rather than in partnership. 

What the Gap Actually Costs You 

The financial impact of poor clinical-billing communication shows up in predictable places: 

Claim denials and delays: Coding mistakes are cited as the biggest concern for 32% of first-submission denials, and many of these trace back to documentation that doesn’t support the billed service level. 

Revenue leakage: Healthcare organizations commonly lose 4-5% of their revenue due to undercoding, overcoding, and documentation gaps. For a practice generating $3 million annually, that’s $150,000 walking out the door. 

Staff burnout: When claims get denied, both teams spend time on rework. The billing team has to investigate and resubmit, and clinical staff must provide additional documentation or clarification. It’s frustrating for everyone. 

Compliance risk: In 2024, 79% of Medicaid improper payments were the result of insufficient documentation. That’s not just lost revenue, that’s an audit risk. 

The most troublesome part? These problems compound over time. A recurring documentation gap that causes repeated denials doesn’t just delay one payment, it creates a pattern that affects cash flow, team morale, and your organization’s ability to plan strategically. 

Where Organizations Get Stuck 

Most healthcare leaders recognize that communication between clinical and billing needs improvement. The challenge is understanding where to start repair work. 

Some organizations assume their EHR will solve the problem automatically. Technology definitely helps, but it can’t replace clear expectations and consistent workflows. An EHR is only as good as what’s put into it, and if clinical staff don’t understand what your billing team needs or why it matters, the documentation gaps persist. 

Other organizations try one-time training sessions. A billing team member presents to clinical staff about documentation requirements, everyone nods, and…nothing changes. Without ongoing dialogue and feedback loops, training fades quickly. 

The biggest trap we see healthcare teams falling into is treating symptoms instead of causes. You can chase down individual denials, follow up on aging AR, and respond to payer pushback all day long. But if you’re not addressing the underlying communication breakdown, you’re just running in place. 

The Leadership Opportunity 

Here’s what most organizations miss: improving communication between clinical and billing teams isn’t just a frontline issue for your teams to work out amongst themselves – it’s a leadership systems issue. 

When leadership expectations around documentation, coding support, and issue resolution aren’t clearly defined and communicated, teams fill in the gaps themselves. That leads to inconsistent practices, informal workarounds, and frustration on both sides. 

The good news? When leaders treat communication as an operational priority rather than an afterthought, the impact shows up quickly in cleaner claims, reduced friction, and a better experience for both staff and patients. 

In Part 2 of this series, we’ll walk through the specific, practical steps organizations can take to build better bridges between clinical and billing teams, from creating shared documentation expectations to establishing feedback loops that actually work. 

Because the truth is, you don’t need a complete overhaul to see meaningful improvement. You just need to know where to start.

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As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
Continue Readiing
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Title

As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
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Navigating Value-Based Care Financial Planning in 2026 

Posted on by Carolyn Yoder

The healthcare landscape is shifting beneath our feet, and for FQHC leaders, the message is clear: value-based care is no longer just a buzzword; it’s becoming a financial imperative. With flat federal funding expected for FY 2026 and traditional fee-for-service models proving increasingly unsustainable, community health centers are facing a pivotal moment. 

The good news? FQHCs have been doing value-based care long before it had a name. Your holistic approach to patient care, your commitment to prevention, and your focus on keeping communities healthy – these are the exact capabilities that value-based payment models reward. 

The Financial Reality Facing FQHCs 

Let’s be honest about the challenges. Sixty-five percent of FQHCs report lacking the financial resources to address unmet patient needs, and with grant funding remaining flat while patient complexity increases, the pressure is real. You’re already stretched thin managing workforce shortages, rising operational costs, and the complex needs of vulnerable populations. 

But here’s where value-based care offers a different path forward. Unlike traditional fee-for-service models that only reimburse for volume, value-based arrangements recognize the comprehensive work you’re already doing – care coordination, preventive services, addressing social determinants of health – and create sustainable revenue streams around those activities. 

Building Your Financial Foundation for Value-Based Success 

Start with Your Data Infrastructure 

The biggest barrier to value-based care success isn’t clinical capability, it’s data visibility. Research from Penn LDI shows that tight budgets limit FQHCs’ capacity to invest in critical technology upgrades, creating a fundamental challenge for value-based care adoption. 

Strong data analytics and population health management capabilities have transitioned from “nice-to-haves” to modern-day essentials. FQHC leadership teams need to see the full picture of patient populations: 

  • Who’s falling through the cracks 
  • Where preventive opportunities exist 
  • How your performance measures against quality metrics 

Investing in robust data systems, whether through partnerships, outsourcing or internal builds, gives you the foundation to track outcomes, demonstrate value, and actually succeed financially under value-based contracts. 

Strengthen Your Revenue Cycle Management 

Value-based care doesn’t eliminate the need for excellent billing practices. If anything, it makes top-notch RCM even more critical. Clean claims, accurate documentation, and efficient AR management protects your cash flow during the transition. Why? When you’re taking on risk-based contracts, every dollar of appropriate reimbursement matters even more. 

Revenue cycle management services that specialize in value-based arrangements can help you navigate the billing complexities that come with blended payment models, ensuring you’re capturing every dollar you’ve earned while freeing your staff to focus on patient care. This becomes especially important as you layer value-based incentives on top of existing PPS payments. 

Invest in Credentialing and Network Readiness 

A Maryland collaborative showed that FQHCs achieved a 35% reduction in emergency department visits and an 11% reduction in hospitalizations under value-based arrangements, but that kind of success requires being properly credentialed and connected within your care networks. 

Whether you’re joining an ACO, participating in MSSP, or negotiating with Medicaid managed care plans, having your providers credentialed across all necessary payers and networks is foundational. Delays in credentialing can mean delayed revenue and missed opportunities. Professional credentialing services ensure you’re positioned to participate fully in value-based programs from day one.

Practical Steps for 2026 

Assess Your Readiness 

Take stock of where you are today: 

  • Do you have the data systems to track patient outcomes across your population? 
  • Can you identify your highest-risk patients and intervene proactively? 
  • Do you understand your total cost of care? 

These questions will reveal your readiness gaps. 

Start Small, But Start Now 

You don’t have to dive into full-risk contracts immediately. While the federal Making Care Primary model is ending in June 2025, there may be state-level programs (like Oregon’s APCM) that are a great fit for your FQHC, depending on your location. Many state Medicaid agencies have developed alternative payment models specifically designed to support community health centers in transitioning to value-based care. Look for opportunities that provide financial rewards for quality improvement without exposing you to downside risk initially. These upside-only models give you runway to build capability while starting to benefit from value-based arrangements. 

Build Your Team’s Capability 

Value-based care requires new skills across your organization, from understanding risk stratification to managing care coordination workflows. Training your staff on what value-based care means operationally, not just conceptually, is essential for successful implementation. 

Negotiate from Strength 

Here’s something many FQHCs don’t realize: you have more negotiating power than you think. FQHCs collectively serve about one in six Medicaid beneficiaries – that’s significant leverage when contracting with health plans. You do not have to accept contracts at face value. Ensure performance metrics account for the complexity of your patient population and that payment rates reflect the reality of serving high-risk communities. 

The Opportunity Ahead 

Just over three-quarters of hospital and health system C-suites say they plan to increase value-based care participation within the next two years. The healthcare industry is moving in this direction whether we’re ready or not. The question isn’t whether to engage with value-based care, it’s how to do it strategically. 

For FQHCs, the transition to value-based care isn’t just about financial survival, it’s about creating a sustainable model that allows you to do more of what you do best: keeping your communities healthy. When you can demonstrate that your preventive care and care coordination reduce emergency visits and hospitalizations, you’re not just improving patient outcomes, you’re proving your financial value to the healthcare system. 

Moving Forward 

The path to value-based care success starts with honest assessment, strategic investment, and deliberate capability building. Focus on: 

  • Strengthening your data infrastructure 
  • Ensuring clean revenue cycle operations 
  • Maintaining proper credentialing across your network 

These foundational elements position you to take on value-based arrangements confidently. 

Remember: the healthcare organizations thriving in value-based models aren’t necessarily the biggest or best-resourced. They’re the ones who understood early that success requires the right infrastructure, the right expertise, and the right partnerships to navigate this new landscape. 

If you’re ready to explore how to strengthen your financial foundation for value-based success, we’d love to talk. Our team understands the unique challenges facing FQHCs and can help you build the revenue cycle capabilities that make value-based care work for your organization and your community. 

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Title

As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
Continue Readiing
image

Title

As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
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Is Your Revenue Cycle Ready for 2026? A Practical Self-Assessment for Healthcare Leaders 

Posted on by Carolyn Yoder

As healthcare organizations enter the new year, many leaders are asking the same question: Are we set up to move forward with confidence, or are we still spending too much time reacting? Between staffing constraints, evolving payer requirements, and continued financial pressure, revenue cycle readiness is less about perfection and more about clarity. 

Whether you lead an FQHC, CHC, specialty practice, or a mission-driven nonprofit, the revenue cycle plays a critical role in sustaining care delivery. Taking time now for a thoughtful, high-level self-assessment can help identify where your organization is well-positioned and where added focus may make the biggest difference in the year ahead. 

Think of this list as a strategic pause – an opportunity to step back and evaluate whether your revenue cycle is supporting your goals or quietly creating friction. Let’s dive in! 

What Revenue Cycle Readiness Really Means Going Into 2026 

Traditionally, revenue cycle performance has been measured by metrics alone: days in AR, denial rates, or net collection percentages. While those indicators still matter, readiness today is broader. 

A “ready” revenue cycle is one that: 

  • Can adapt to staffing changes without major disruption 
  • Provides leadership with confidence that the data they rely on is accurate and meaningful 
  • Supports sustainable growth without burning out internal teams 
  • Aligns financial operations with organizational mission, both for nonprofit and for-profit healthcare teams 

Readiness is not about having everything optimized at once. Instead, it’s about knowing where you stand and having a plan to address the areas that matter most. 

A Practical Self-Assessment for Healthcare Leaders 

Below are key areas many we have helped organizations review as they prepare to tackle a new year. These questions are intentionally high-level and designed to help leadership teams engage in strategic reflection rather than just tackling troubleshooting. 

Staffing and Team Capacity 

Revenue cycle teams remain stretched across the healthcare industry, making capacity a critical consideration. A lack of breathing room often shows up downstream in delays, rework, and missed opportunities. 

Questions for your team: 

  • Do you feel confident your current staffing model can support your expected patient volume in 2026? 
  • Are key processes dependent on one or two individuals? 
  • When challenges arise, is your team able to respond proactively, or is it mostly in reaction mode? 

Front-End Stability 

Strong revenue cycles start before a claim is ever submitted. Small breakdowns at the front end tend to create outsized impacts later in the cycle. 

Questions for your team: 

  • Are front-end processes consistent across locations or departments? 
  • Do billing and registration teams share visibility into recurring issues? 
  • When payer requirements change, is there a clear path for updates to be communicated and applied? 

Denials and Rework Trends 

Denials are inevitable, but your denial patterns tell an important story. Without clear insight, teams often spend valuable time fixing the same issues repeatedly. 

Questions for your team: 

  • Are you able to identify trends rather than just individual denials? 
  • Do you understand why rework is happening, not just where? 
  • Is denial data used as a learning tool or simply a reporting requirement? 

Accounts Receivable Health 

AR is often a reflection of operational alignment. Healthy AR supports cash flow and reduces stress across the organization. 

Questions for your team: 

  • Do you have a clear sense of what is driving your current AR balance? 
  • Are backlogs growing, shrinking, or staying the same? 
  • How often is AR reviewed from a strategic perspective, not just a transactional one? 

Credentialing and Enrollment Confidence 

Enrollment delays can quietly erode revenue. Confidence in this area reduces surprises and supports smoother growth. 

Questions for your team: 

  • Do new providers become fully billable within a predictable timeframe? 
  • Are re-credentialing deadlines easy to track and manage? 
  • Can leadership quickly assess the revenue impact of enrollment issues? 

Reporting and Leadership Visibility 

Good decisions rely on trusted information. If your data and regular reports raise more questions than answers, it may be time to reassess reporting processes. 

Questions for your team: 

  • Do leaders feel confident in the reports they review? 
  • Are reports timely and easy to interpret? 
  • When numbers change, is there clarity around the “why” behind them? 

What Your Answers Reveal and How to Prioritize Next Steps 

As you reflect on these questions with your leadership team, you should see patterns emerging. For example, staffing strain combined with growing AR may point to process gaps rather than a lack of staff effort. Front-end challenges paired with denial trends may signal a need for better cross-team communication. 

The goal is not to tackle everything at once. Instead: 

  • Identify one or two areas creating the most friction 
  • Focus on issues that consistently resurface 
  • Prioritize changes that relieve pressure on your internal team 

For many organizations, this is where targeted support can help. A billing department assessment or coding audit, for example, can provide an objective view of what’s working, what isn’t, and where adjustments could have the greatest impact for your team without requiring a full overhaul. 

A focused review with outside experts that know your state and specialty can give you clarity you can act on quickly. 

Readiness Is About Support, Not Perfection 

Preparing your revenue cycle for the coming year doesn’t require flawless operations. It requires awareness, prioritization, and the right level of support. By taking time now to assess readiness at a strategic level, healthcare leaders can move into the new year with greater confidence and fewer surprises. 

If this self-assessment raises questions or confirms areas you’ve been meaning to revisit, it may be worth starting a deeper conversation. Practice Management works alongside healthcare organizations as a collaborative teammate, and our services are designed to help teams strengthen their revenue cycle in ways that fit their unique needs. 

Sometimes, a fresh perspective is all it takes to turn uncertainty into a clear path forward!  

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Title

As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
Continue Readiing
image

Title

As we near the end of the year, many of the healthcare organizations we work with are beginning to look forward and plan for 2024. Part of this planning is updating, or even creating, a strategic plan. Strategic planning can be defined as “a process used by organizations to identify their goals, the str
Continue Readiing

Streamlining Sliding Fee Discount Programs for Maximum Compliance and Revenue 

Posted on by Carolyn Yoder

Sliding fee discount programs are at the heart of community care. They help patients feel welcome, remove financial barriers, and ensure that everyone – regardless of income – can access high-quality healthcare. For FQHCs, CHCs, and nonprofit clinics, these programs represent both your mission in action and a meaningful way to support long-term financial health. 

When managed with clarity and consistency, sliding fee discount schedules make care more accessible, improve patient trust, and help clinics remain good stewards of federal guidelines. This month, we’re sharing practical strategies to help your team refine your program, strengthen compliance, and maintain strong revenue flow while continuing the incredible work you’re already doing. 

The Importance of a Clear, Patient-Centered Sliding Fee Program 

A well-designed sliding fee program is one of the clearest ways to demonstrate that no patient will be turned away because of financial hardship. Federal guidance requires discount schedules based solely on income and family size. This structure is designed to promote fairness and ensure that discounts are offered consistently and transparently. 

Clinics that keep these systems simple and easy to navigate for patients and staff alike, often see smoother intake processes, stronger community trust, and fewer patient concerns about cost. When patients understand the program and feel supported, they are more likely to keep appointments and stay engaged in care, which benefits both clinical outcomes and financial performance. 

A patient-centered sliding fee program does more than reduce barriers. It reinforces your values: dignity, equity, and access for all. 

Making Eligibility and Documentation Supportive and Easy 

Eligibility verification doesn’t have to feel intimidating or complicated for patients or staff. The most effective sliding fee programs are the ones that keep documentation straightforward and communication friendly. When teams know exactly what they need to collect and why, the process becomes faster for staff and less stressful for patients. 

Start with a clear policy grounded in federal requirements. From there, streamline the application so it’s simple to complete and easy to translate into multiple languages. Many clinics find success when they normalize the sliding fee program by talking about it early and often, from front desk phone scripts to signage, to appointment reminders. 

A supportive documentation approach encourages: 

  • Transparent, culturally respectful communication 
  • Annual re-verification that fits into existing workflows 
  • Accessible, multilingual materials 
  • A welcoming tone that empowers patients instead of intimidating them 

These small touches go a long way in building trust and easing anxiety about cost. 

Strengthening Billing Processes While Preserving Access 

Sliding fee discounts and strong billing practices can work hand in hand. When discount tiers are built seamlessly into your practice management or billing systems, your team spends less time correcting errors and more time supporting patients. 

Rather than seeing discounts as lost revenue, many clinics view them as a pathway to steady, predictable financial performance. Clear sliding fee configurations ensure that insured patients are charged only the appropriate out-of-pocket amount and that nominal fees remain fair and manageable. 

Organizations often benefit from periodically reviewing their configurations and making sure: 

  • Discount levels are loaded correctly into the EHR or billing system 
  • Nominal fees remain minimal and patient-friendly 
  • Staff feel confident applying discounts during check-in or check-out 
  • Any patterns in write-offs or credit balances are used for quality improvement 

These habits keep your financial processes running smoothly while preserving accessibility for low-income patients. 

Designing Discount Schedules That Support Both Mission and Sustainability 

One of the strengths of sliding fee programs is how flexible they can be. Many clinics tailor their discount tiers not only around federal poverty guidelines but around service types and community needs. This allows clinics to protect access for essential services while balancing the cost of providing higher-complexity care. 

A thoughtful review every few years can help ensure your sliding fee schedule continues to align with local economic changes, reimbursement shifts, and patient needs. When organizations look at utilization trends, patient feedback, and community demographics, they’re often able to make refinements that support both sustainability and equitable access. 

In many cases, the most successful programs grow out of feedback from staff and patients, which is a great reminder that sliding fee schedules aren’t just compliance tools; they’re part of your mission to meet people exactly where they are. 

Staying Aligned With Requirements Through Consistency and Communication 

Preparing for compliance reviews doesn’t have to be stressful. Most health centers already have strong structures in place, so your goal is simply making sure everything is documented clearly and applied consistently across the team. 

A supportive compliance strategy may include: 

  • An up-to-date sliding fee policy that is easy to reference 
  • A simple process for storing and retrieving documentation 
  • Regular staff refreshers to make sure everyone is on the same page 
  • Clear communication with patients when discount levels or policies are updated 

These steps not only support audit readiness but also help team members feel confident and empowered. When staff understand the “why” behind the program and feel equipped to explain it, the entire process becomes smoother for everyone involved. 

Final Thoughts: Sliding Fee Programs Are an Opportunity, Not a Burden 

Sliding fee discount programs embody the heart of community-based healthcare: welcoming every patient with dignity, compassion, and fairness. When these programs are thoughtfully structured, communicated clearly, and supported with strong workflows, they strengthen your mission and improve your financial stability at the same time. 

Whether your organization is updating policies, refining workflows, or preparing for the new year, now is a great time to revisit your sliding fee program with a fresh, supportive perspective.  

And if your team could use help reviewing workflows, optimizing billing systems, or ensuring your discount program aligns with revenue cycle best practices, the Practice Management team is here to support you.