Tag Archives: referrals

FAQs – Chronic Care Management

Care providers across the United States of America are monetizing Medicare chronic care management billing reimbursement codes to increase revenue from their practice. Read on to find answers to all the most commonly asked questions about patient eligibility, the scope of services, CPT codes and payment reimbursement for Medicare CCM.

Patient Eligibility

FAQ: Are all Medicare patients eligible for CCM reimbursement?

Answer: According to the Centers for Medicare & Medicaid Services (CMS), CCM is for “patients with two or more chronic conditions. A chronic condition is expected to last at least 12 months or the patient’s entire lifetime. The condition should be diagnosed to place the patient at significant risk of death, or functional decline.

FAQ: How can a care provider decide which condition meets CMS’ definition for CCM eligibility?

Answer: CMS has not specified or listed the eligible chronic conditions that meet this definition. CMS does have a databank regarding chronic conditions (http://www.ccwdata.org) that care providers can use. However, this list is very narrow. In general practice, CMS requires a clear communication within the care plan that the chronic conditions being treated post a significant risk of death or functional decline.

FAQ: Are there only certain diagnoses for which the CCM code can be reported?

Answer: There is not a defined list of diagnosis codes that meet the requirements of. What is required is that the chronic conditions place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline and that management requires a care plan. The AAN recognizes patients with two or more of the following conditions may be appropriate for the use of chronic care management services*:

Neurocognitive disorders including Alzheimer’s disease, Dementia, and Parkinson’s disease
Stroke with late effects that place the patient at risk for falls, fractures, and aspiration pneumonia
Poorly controlled diabetes mellitus

FAQ: What about patients who are Medicare beneficiaries but also eligible for Medicaid?

Answer: CMS CPT codes can be used while billing for CCM treatment given to Medicare beneficiaries who are also eligible for Medicaid.

FAQ: How to kick-start the process of bringing a patient under CCM care?

Answer: An initial appointment must be fixed for a comprehensive evaluation of the patient. This is known as a “Welcome to Medicare” visit and includes an initial preventive physical examination. A patient must have received an introduction to Medicare CCM billing in person to be able to bill separately for CCM services. Until the changes made in 2017, a consent form signed by the patient was mandatory during the patient’s initiation into the CCM program. As per the CMS requirement, the consent form is no longer mandatory.

FAQ – Can CCM services be reported if the patient/caregiver has not given consent?

Answer: No. One of the requirements for billing CCM services is “knowledge and recognition by the patient that the physician will perform care management services on the patient’s behalf.” In the event of an audit, documentation of patient consent in the patient record is crucial.

Scope of Services

FAQ: What are the scope of services for CCM reimbursement as defined by CMS?

Answer: CMS defines the scope of CCM services in the following way:

Provide patients with access to care management services at any time of the day. This means patients should be able to contact the care provider during any emergency or urgent chronic care need 24-hours-a-day, 7-days-a-week. This may be through calls, SMS, email, internet applications or other means agreed upon by the patient and care provider.
Established care continuity with a designated provider with whom the patient is able to schedule appointments, discuss care plan compliance, report vital stats and discuss any discomfort that arises.
Creation of a patient-centered care plan document taking into consideration the physical, mental, functional and environmental factors of the patient. This includes an assessment of the support system and resources accessible to the patient.
Care management for chronic conditions including assessment of patient’s medical, functional, and psychosocial needs. Regular follow-ups to ensure timely receipt of all recommended preventive care services, adherence to the suggested care plan and timely medication.
Regular follow-up after a patient visits the emergency department, after discharges from the hospital or other healthcare facilities. Coordination with home/community based clinical service providers to support a patient’s care plan adherence.
Use of certified electronic health record (EHR) and a patient consent form were mandatory until the changes in 2017 which made them optional.

Chronic Care Management CPT Billing Codes and Payment

FAQ: Which CMS Medicare billing codes can be used to bill CCM?

Answer: For the chronic codes that can be billed are below.

CPT Code	Billing Amount(approx) per consultation	Description
CPT99490	$42	Min 20min non-face to face time monitoring the care plan
CPT99480	$60	Min 60min non-face to face consultation time establishing or monitoring a care plan
CPT99489	$47	To be billed with CPT 99487 for every additional 30 min of non-face to face consultation

FAQ: Are CCM services subject to Medicare’s co-paying system?

Answer: Yes. After the deductible is met, the 20 percent coinsurance charged to the patient will be about $8 to $9 for a month’s work of CCM with CPT 99490.

FAQ: Can you bill CCM for patients in an assisted living facility?

Answer: According to CMS, CPT code 99490 can be billed only for CCM services provided to a patient who is currently not the inpatient of a hospital. The patient must not be residing in a facility that receives payment from Medicare for that beneficiary.

FAQ: Is billing for CCM services limited to primary care physicians?

Answer: Physicians and Non-Physicians can claim reimbursement by billing for CCM CPT Codes. CCM code is most likely to be billed by primary care physicians. However, specialists, nurse practitioners, physician assistants, clinical nurse specialists and certified nurse midwives who meet the requirements may also bill for these services.

FAQ: Can the non-face-to-face time spent creating the care plan count toward the 20 minutes necessary to bill 99490?

Answer: Yes, it can.

FAQ: What is the difference between chronic care management (99490) and complex chronic care management services (99487, 99489)?

Answer: Complex chronic care management services include the same criteria as the chronic care management service, plus an additional requirement of the establishment or substantial revision of a comprehensive care plan, medical decision-making of moderate to high complexity, and at least 60 minutes of clinical staff time.

Care Plan

FAQ: What does the care plan have to include as required by CMS?

Answer: The plan of care should include details of the following elements:

Problem list detailing the chronic conditions the patient suffers from
Expected outcome and the likely course of the disease
Measurable treatment goals
Symptom management
Planned interventions through regular follow-ups and vital data collection from patient
Medication management depending on any concerns/reactions/improvement reported by the patient
Care coordination plan between care provider and patient’s caregiver such as family/nurse/community housing etc
Requirements for periodic review and revision of the care plan as required.

FAQ: Do I have to provide the patient with a copy of the care plan?

Answer: Yes. CMS requires the care provider to share the care plan with the patient in a written or electronic format.

FAQS – Patient Referral Management

There has been a buzz around Patient Referral Management recently. Practices have considerable concern about how Patient Referral Management works and the related organizational components. This blog documents the Frequently Asked Questions by general practices in the U.S. and answers for the same.

FAQ – What is Patient Referral Management?

Answer – Patient Referral Management is the process of monitoring, directing and controlling patient referrals. It varies according to the nature of a practice and encompasses a range of different functions. Referral management centers may send referrals to specialty care or receive referrals from primary care. In addition to analyzing patient referral data, it also includes

Patient appointment scheduling
Communicating referral updates to the physicians
Referral process feedback
Referral loop closure

FAQ – How does a Patient Referral Management work?

Answer – It can vary depending on the nature of a practice. When patients need advanced treatment or additional diagnosis that cannot be given within the practice, they are referred to a specialist/imaging centre. The PCP identifies the need for a referral and places a request with the referral coordination team. The referral coordinator does the insurance pre-authorization and finds the right specialist for the referral. Then the referral coordinator sends the referral. Now the specialist validates the referral information and coordinates with the referring physician for missing information. The specialist then schedules appointments and takes care of the patient. The specialist must give timely updates to the referring physician. After the referral is over, the referring physician closes the referral loop.

FAQ – What are the medico-legal risks?

Answer – Some of the possible risks involved in a Patient Referral Management process include:

The referral letter getting lost in the process
Delays in the patient being seen by a specialist
The patient being seen by an inappropriate specialist (at the behest of the RMC)
The referral being returned to the practice when it is, in fact, needed
Whether referring through Patient Referral Management may breach patient confidentiality.

FAQ – Is patient confidentiality at risk?

Answer – In line with General Medical Council advice, practices should tell patients if their referral letter will be sent via a referral management centre.

Paragraphs 25-27 of the GMC’s Confidentiality (2009) state

Most patients understand and accept that information must be shared within the healthcare team in order to provide their care. You should make sure information is readily available to patients explaining that, unless they object, personal information about them will be shared within the healthcare team, including administrative and other staff who support the provision of their care.
This information can be provided in leaflets, posters, on websites, and face to face and should be tailored to patients’ identified needs as far as practicable. Posters might be of little assistance to patients with sight impairment or who do not read English, for example. In reviewing the information provided to patients, you should consider whether patients would be surprised to learn about how their information is being used and disclosed.
You must respect the wishes of any patient who objects to particular information being shared within the healthcare team or with others
providing care, unless disclosure would be justified in the public interest. If a patient objects to a disclosure that you consider essential to the
provision of safe care, you should explain that you cannot refer them or otherwise arrange for their treatment without also disclosing that
information.

If the patient objects to the involvement of the RMC, the practice should respect their wishes and make the referral direct to the consultant, if that is possible. The referring practice should, however, be able to rely on a duty of confidentiality at the RMC which is comparable to their own.

FAQ – Why go for a Patient Referral Management software?

Answer – Patient Referral Management process is currently too manual and requires a lot of time and effort. A Patient Referral Management software helps in automating the process. It eases the process of,

Insurance pre-authorization
Finding the right receiving provider
Patient coordination and communication
Referral updates to the referring physicians

FAQ – Whom does a Patient Referral Management Software benefit?

Answer – A Patient Referral Management Software helps in automating the manual process of managing patient referrals. It benefits all the stakeholders involved in a referral process. They are,

Referring physician – A referring physician identifies the need for a referral and initiates the same. A Patient Referral Management Software reduces the processing time of the referrals. It saves a lot of time and effort for referring physicians.
Referral coordinators – Referral coordinators do the insurance pre-authorization and also they also find the right specialist. They are made to handle many software at the same time. A single Patient Referral Management Software can help in easing the process for them.
Receiving providers – The specialists have tough time managing referrals from various channels and also fail to communicate effectively with the patient and the referring physicians. A Patient Referral Management Software can automate the process by channelizing the referrals into a single queue and also help in effective communication.
Patients – A software can help patients by reducing their efforts in communicating between the referring and receiving providers. It also enhances patient experience by reducing care fragmentation.

FAQ – Which organizations can use a Patient Referral Management software?

Answer – A Patient Referral Management software can help organization who send or receive referrals. Community Clinics and Federally Qualified Health Centres (FQHCs) send out referrals. They can use a Patient Referral Management software to track and manage their referrals. Specialist clinics and Imaging centres who receive referrals can use this software to manage their referrals and patient appointments efficiently. Large Enterprise Hospitals send and receive referrals. They can use a Patient Referral Management Software to track how many referrals are flowing in and out of their network.

FAQ – Does a Patient Referral Management software help both inbound and outbound referrals?

Answer – Inbound is when referrals are received in a practice and outbound is when referral are sent to a practice. As mentioned earlier, a Patient Referral Management can help in both sending and receiving referrals. Both inbound and outbound heavy practices can benefit from a Patient Referral Management software.

FAQ – How to implement a Patient Referral Management software?

Answer – A Referral Management software must identify the pain points in the current workflow and try to fit in by solving the challenges. For instance, before our HealthViewX Patient Management software is implemented, we do a few steps,

Understand the practice’s challenges and what they predominantly need to solve
Study the practice’s workflow completely
Propose a solution wherein it can fit in their existing workflow
Implement the solution without disrupting their existing system

Ideally, any Patient Referral Management software should follow the above for easy implementation.

FQHC Statistics – Growth, Region, Performance and Revenue – Federally Qualified Health Centers across the USA

What are Federally Qualified Health Centers (FQHCs)?

Federally Qualified Health Centers (FQHCs) in the United States are non-profit entities that are composed of clinical care providers, who operate at comprehensive federal standards. FQHCs were originally intended to provide the medically underserved population with quality care to minimize patient load in hospital emergency rooms.

According to Medicare and Medicaid statutes, FQHCs receive federal funding under Section 330 of the Public Health Service (PHS) Act to provide comprehensive primary care services to uninsured and underinsured populations thus ensuring that comprehensive care is available to all, regardless of income or insurance status. Medicare pays FQHCs based on the FQHC Prospective Payment System (PPS) for medically necessary primary health services and qualified preventive health services given by an FQHC practitioner.

To receive federal funding, FQHCs must meet the following requirements:

Be located in a federally designated medically underserved area (MUA) or serve medically underserved populations (MUP)
Provide comprehensive primary care
Adjust charges for health services on a sliding fee schedule according to patient income
Be governed by a community board of which a majority of members are patients at the FQHC

The Growth of FQHCs

In the early 1960s, there were only 8 health centers in the U.S. Ever since then, the numbers have increased exponentially. By 2001, there were 748 health centers at 4,128 service sites around the nation, serving approximately 10 million individuals.

Federal funding for health centers has increased from $750 million in 1996 to $2.2 billion in 2010. Federal support has increased tremendously over the last 10 years. In 2011, there were 1,128 health centers providing care to more than 8,000 rural and urban delivery sites in the U.S. and territories. Today, there are 1,400 organizations with 11,200 facilities serving about 25 million individuals every year.

The above chart shows the growth of health centers from its inception in 1980 till 2020. The chart also shows the exponential increase in the number of patients served over the years.

FQHCs in various regions across the U.S

State	State Code	Number of FQHCs
California	CA	178
Texas	TX	73
New York	NY	70
Florida	FL	48
Ohio	OH	47
Illinois	IL	45
Pennsylvania	PA	44
North Carolina	NC	40
Michigan	MI	39
Massachusetts	MA	39
Georgia	GA	35
Louisiana	LA	36
Oregon	OR	33
West Virginia	WV	31
Tennessee	TN	30
Alaska	AK	28
Missouri	MO	28
Washington	WA	27
Virginia	VA	26
Indiana	IN	25
Kentucky	KY	23
New Jersey	NJ	23
South Carolina	SC	23
Arizona	AZ	21
Mississippi	MS	21
Colorado	CO	21
Oklahoma	OK	20
Maine	ME	20
Kansas	KA	18
Maryland	MD	17
Montana	MT	17
New Mexico	NM	17
Wisconsin	WI	18
Connecticut	CT	17
Minnesota	MN	16
Alabama	AL	15
Hawaii	HI	14
Iowa	IA	14
Idaho	ID	14
Puerto Rico	PR	14
Utah	UT	13
Arkansas	AR	12
New Hampshire	NH	11
Vermont	VT	11
District of Columbia	WDC	8
Rhode Island	RI	8
Nebraska	NE	7
Nevada	NV	7
Wyoming	WY	6
South Dakota	SD	5
North Dakota	ND	4
Delaware	DE	3
Virgin Islands	VI	3
Guam	GU	2
Northern Mariana Islands	MP	2

Performance of FQHCs

Figure 2 – Health Centers Perform Better on Ambulatory Care Quality Measures than Private Practice Physicians

The above chart shows how health centers have outperformed private practice physicians in every aspect of service.

Figure 3 – Health Centers Provide More Preventive Services than Other Primary Care Providers

The above chart shows a comparison between health centers and other providers based on the number of patient visits for various ailments.

Figure 4 – Health Center Patients Are More Satisfied with the Overall Care Received Compared with Low Income Patients Nationally

The above chart shows the level of satisfaction of low-income patients. Health center patients have a huge level of satisfaction as compared to other low-income patients nationally.

Financing and Reimbursements for FQHCs

FQHCs are required by law to provide services to all people, regardless of ability to pay. The uninsured are charged for services on a board-approved sliding-fee scale, which is based on a patient’s family income and size.

FQHCs are financed through various methods. These include a mix of Medicaid and Medicare reimbursements (with different payment methodologies), direct patient revenue, other third-party payers (private insurers), state funding, local funding, philanthropic organizations, and grant funding from the Bureau of Primary Health Care (BPHC) of HRSA of the U.S. Department of Health and Human Services (HHS).

The above chart shows the revenue distribution of FQHCs based on payer source (2018).

FQHC Revenue across all regions in the U.S (approx. 2018)

Source:
George Washington University analysis of the Health Resources and Services Administration’s Uniform Data System. Special Data Request, September 2019.

Location	Medicaid	Medicare	Private Insurance	Self-Pay	Federal Section 330 Grants	Other Grants and Contracts	Other	Total
United States	$12,958,743,457	$2,260,247,981	$3,048,512,406	$1,248,741,884	$4,829,287,467	$3,336,624,219	$1,007,447,180	$28,689,604,594
Alabama	$52,785,795	$17,803,287	$17,114,860	$12,744,350	$83,625,546	$13,471,556	$4,344,085	$201,889,479
Alaska	$102,348,854	$18,671,815	$37,698,230	$6,477,465	$67,692,068	$119,544,705	$2,756,393	$355,189,530
Arizona	$337,972,854	$47,634,000	$71,949,881	$23,395,361	$83,428,217	$41,485,739	$5,472,766	$611,338,818
Arkansas	$62,148,511	$24,046,228	$30,622,521	$12,429,111	$54,555,352	$9,120,521	$1,735,385	$194,657,629
California	$3,704,343,504	$411,514,109	$291,192,054	$148,976,225	$658,760,061	$615,047,232	$334,581,140	$6,164,414,325
Colorado	$319,775,816	$39,134,784	$48,657,089	$30,779,398	$106,101,957	$95,942,011	$20,709,084	$661,100,139
Connecticut	$228,434,332	$32,127,164	$26,544,878	$11,568,619	$59,696,129	$50,791,682	$10,598,421	$419,761,225
Delaware	$11,773,644	$1,479,685	$2,463,464	$4,386,233	$13,557,989	$5,219,063	$470,309	$39,350,387
District of Columbia	$160,105,430	$22,175,379	$32,105,709	$5,512,030	$27,476,019	$31,943,055	$7,236,844	$286,554,466
Florida	$391,497,340	$60,674,510	$209,954,679	$81,714,253	$236,911,216	$193,834,424	$17,832,728	$1,192,419,150
Georgia	$66,177,853	$48,142,417	$57,295,748	$30,758,262	$117,787,006	$28,848,026	$9,877,675	$358,886,987
Hawaii	$107,408,992	$15,806,563	$17,253,126	$5,783,071	$31,398,131	$32,520,603	$3,907,118	$214,077,604
Idaho	$45,572,373	$21,289,644	$50,122,229	$22,535,206	$45,993,298	$25,577,164	$3,267,335	$214,357,249
Illinois	$455,197,448	$56,238,990	$131,100,822	$64,116,380	$201,027,383	$137,469,419	$29,398,121	$1,074,548,563
Indiana	$200,004,374	$20,647,447	$30,284,051	$18,433,251	$75,547,860	$28,756,217	$30,759,622	$404,432,822
Iowa	$83,853,103	$13,542,737	$23,553,367	$12,655,645	$38,528,294	$19,319,034	$1,624,245	$193,076,425
Kansas	$37,808,462	$19,789,301	$26,840,099	$15,221,728	$44,761,541	$16,668,896	$4,665,564	$165,755,591
Kentucky	$176,573,940	$46,631,367	$68,598,016	$24,819,874	$80,881,354	$6,773,516	$6,597,845	$410,875,912
Louisiana	$146,815,697	$31,043,111	$59,995,751	$11,587,230	$100,474,957	$30,961,276	$4,441,509	$385,319,531
Maine	$41,882,541	$35,423,228	$47,436,524	$12,099,407	$43,787,648	$11,360,335	$6,280,495	$198,270,178
Maryland	$150,688,381	$29,260,626	$73,964,146	$13,146,680	$57,449,364	$35,657,860	$21,090,583	$381,257,640
Massachusetts	$362,280,706	$103,012,238	$165,134,454	$27,248,100	$128,238,080	$258,007,270	$160,820,426	$1,204,741,274
Michigan	$314,285,715	$68,214,766	$79,638,020	$28,291,497	$127,807,919	$44,375,118	$9,855,849	$672,468,884
Minnesota	$75,452,268	$12,577,519	$16,837,190	$11,935,453	$42,977,632	$29,987,097	$4,128,981	$193,896,140
Mississippi	$32,037,428	$18,436,338	$22,813,575	$21,440,111	$74,626,865	$14,886,816	$1,657,237	$185,898,370
Missouri	$255,311,813	$26,546,831	$59,184,521	$28,003,100	$110,804,809	$33,834,797	$10,235,337	$523,921,208
Montana	$34,073,242	$12,203,723	$17,685,163	$7,521,912	$42,126,575	$10,185,208	$6,307,871	$130,103,694
Nebraska	$19,899,828	$1,982,820	$13,342,672	$7,991,555	$22,106,057	$22,906,355	$1,933,464	$90,162,751
Nevada	$33,773,688	$11,166,606	$12,531,690	$3,172,460	$21,069,529	$15,948,721	$706,509	$98,369,203
New Hampshire	$21,695,854	$17,132,960	$22,653,425	$5,099,829	$24,039,213	$11,899,812	$2,725,189	$105,246,282
New Jersey	$158,938,887	$11,758,143	$14,145,131	$21,606,309	$81,666,571	$69,281,662	$5,982,249	$363,378,952
New Mexico	$132,429,129	$26,364,684	$24,132,532	$15,923,683	$76,523,082	$57,190,428	$4,530,396	$337,093,934
New York	$1,461,356,192	$201,623,297	$250,926,163	$50,171,017	$269,626,284	$385,124,022	$91,523,863	$2,710,350,838
North Carolina	$90,190,949	$59,012,065	$65,516,943	$50,837,624	$133,899,942	$40,248,341	$26,574,283	$466,280,147
North Dakota	$11,640,795	$3,863,326	$9,419,592	$4,474,860	$10,746,019	$908,251	$1,001,661	$42,054,504
Ohio	$261,827,729	$51,042,970	$58,596,828	$25,007,037	$146,210,064	$41,839,517	$21,051,011	$605,575,156
Oklahoma	$58,934,312	$20,089,581	$28,480,968	$19,992,107	$58,679,531	$10,582,038	$2,883,612	$199,642,149
Oregon	$394,118,738	$51,503,384	$31,974,615	$15,310,703	$91,700,505	$91,028,195	$7,602,558	$683,238,698
Pennsylvania	$315,531,242	$68,519,997	$104,374,387	$17,072,987	$128,243,325	$37,490,171	$10,326,309	$681,558,418
Rhode Island	$109,670,334	$15,761,096	$19,797,174	$5,830,348	$28,040,434	$14,890,907	$4,960,361	$198,950,654
South Carolina	$95,328,346	$89,583,350	$103,316,045	$25,145,381	$89,314,251	$31,444,029	$18,322,528	$452,453,930
South Dakota	$11,514,028	$4,903,220	$10,207,221	$6,525,886	$17,900,812	$3,435,235	$1,231,547	$55,717,949
Tennessee	$80,779,671	$26,920,974	$41,375,639	$15,091,806	$87,348,642	$31,856,403	$3,747,729	$287,120,864
Texas	$405,350,935	$68,050,313	$170,985,325	$92,159,958	$258,162,160	$309,998,557	$26,687,781	$1,331,395,029
Utah	$29,700,875	$11,520,256	$16,681,038	$13,794,751	$39,878,950	$24,880,704	$3,574,692	$140,031,266
Vermont	$47,210,527	$31,973,872	$34,695,192	$23,137,643	$23,463,366	$7,348,657	$8,511,984	$176,341,241
Virginia	$54,549,880	$39,744,588	$42,438,653	$26,005,991	$85,805,735	$20,677,091	$4,357,021	$273,578,959
Washington	$769,937,162	$89,428,910	$129,151,433	$58,320,292	$139,027,744	$94,896,347	$14,596,022	$1,295,357,910
West Virginia	$116,781,516	$57,847,408	$83,808,357	$28,402,025	$68,591,429	$16,910,711	$12,143,151	$384,484,597
Wisconsin	$149,327,704	$8,202,250	$27,257,452	$10,451,845	$45,790,614	$27,262,928	$7,630,433	$275,923,226
Wyoming	$6,918,264	$4,226,082	$5,490,411	$3,411,365	$7,478,734	$1,763,502	$477,559	$29,765,917
American Samoa	$786,753	$0	$0	$0	$3,082,370	$0	$0	$3,869,123
Federated States of Micronesia	$0	$0	$24,112	$84,319	$3,186,592	$0	$0	$3,295,023
Guam	$2,451,828	$53,941	$17,002	$132,489	$2,173,874	$2,330,520	$137,227	$7,296,881
Marshall Islands	$0	$0	$0	$31,865	$1,061,772	$1,086,917	$0	$2,180,554
Northern Mariana Islands	$98,987	$641	$7,161	$11,185	$677,559	$0	$122,655	$918,188
Palau	$0	$0	$259,006	$1,461,345	$940,810	$50,000	$0	$2,711,161
Puerto Rico	$153,566,707	$33,237,486	$10,276,689	$7,922,019	$103,150,074	$16,880,374	$3,452,418	$328,485,767
U.S. Virgin Islands	$7,822,181	$665,954	$589,383	$581,248	$3,678,153	$4,875,184	$0	$18,212,103

Definitions:
*Medicaid*: also includes the Children’s Health Insurance Program (CHIP), family planning programs, and state-funded coverage programs.

*Private Insurance*: includes employer-sponsored insurance and insurance purchased in the individual market (including the Marketplaces).

*Federal Section 330 Grants*: grants provided by the Health Services Resources Administration, Bureau of Primary Health Care under Section 330 of the Public Health Service Act.

*Other Grants and Contracts*: includes federal grants other than Section 330 grants, grants from state and local governments and private foundations, payments from state and local indigent care programs, and contracts.

*Other*: includes non-patient related revenue, such as fundraising, interest income, rent from tentants, etc.

Future of FQHCs

FQHCs have had significant growth in the past decades. The statistical data indicates that FQHCs have the potential to serve more patients by improving the quality of care. To provide quality care and improve patient experience, FQHCs must invest in the right technology like HealthViewX Care Orchestration Platform which provides the best solutions for the major challenges faced by the health centers.

Reference:

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/fqhcfactsheet.pdf
Kaiser Commission on Medicaid and the Uninsured (data from the National Association of Community Health Centers and the Uniform Data System (UDS) of the Health Resources and Services Administration (HRSA).
Goldman, LE et al. Federally Qualified Health Centers and Private Practice Performance on Ambulatory Care Measures. American Journal of Preventive Medicine. 2012. 43(2):142-149. *Fontil et al. Management of Hypertension in Primary Care Safety-Net Clinics in the United States: A Comparison of Community Health Centers and Private Physicians’ Offices. Health Services Research. April 2017. 52:2.
2015 Uniform Data System. Bureau of Primary Health Care, HRSA, DHHS. National Center for Health Statistics. NCHS Data Brief. No. 220. November 2015. Hypertension Prevalence and Control Among Adults: United States, 2011 – 2014. National Committee for Quality Assurance. Comprehensive Diabetes Care, The State of Healthcare Quality (2016).
Shi L, Tsai J, Higgins PC, Lebrun La. (2009). Racial/ethnic and socioeconomic disparities in access to care and quality of care for US health center patients compared with non-health center patients. J Ambul Care Manage 32(4): 342 – 50. Shi L, Leburn L, Tsai J and Zhu J. (2010). Characteristics of Ambulatory Care Patients and Services: A Comparison of Community Health Centers and Physicians’ Offices J Health Care for Poor and Underserved 21 (4): 1169-83. Hing E, Hooker RS, Ashman JJ. (2010). Primary Health Care in Community Health Centers and Comparison with Office-Based Practice. J Community Health. 2011 Jun; 36(3): 406 – 13.
Shi L, Lebrun-Harris LA, Daly CA, et al. Reducing Disparities in Access to Primary Care and Patient Satisfaction with Care: The Role of Health Centers. Journal of Health Care for the Poor and Underserved. 2013; 24(1):56-66.
George Washington University analysis of the Health Resources and Services Administration’s Uniform Data System. Special Data Request, March 2018.
Community Health Center Revenues by Payer Source.

Improve Your FQHC’s Operational Efficiency And Increase Your Revenue

Money inflow is very important for medical practices. Without a constant source of revenue, medical practices cannot pay bills, pay employees or take care of patients. It is no different for Federally Qualified Health Centers.

What are FQHCs and how do they operate?

FQHCs are community-based primary care medical practices. They provide comprehensive health care services for people of all ages, regardless of their ability to pay or health insurance status. They form a critical component of the health care safety-net as they provide

Primary care
Preventive care (oral health and mental health/substance abuse) services

FQHCs are also called Community Health Centers, Migrant or Homeless Health Centers, and 330-Funded Clinics.

The mission of FQHCs is to enhance primary care services to the underserved in both urban and rural communities. They operate as nonprofit entities under the guidance of a board of directors selected from the community where they operate. In return for providing care to the underserved and uninsured, FQHCs receive Federal government cash grants, cost-based reimbursements for their Medicaid patients, and malpractice coverage. These practices not only maximize the effect of the federal investment going to local patient care but also expands the impact of the Medicaid and Medicare programs.

Why should FQHCs concentrate on improving operational efficiency and increasing revenue?

FQHCs play an important role in supporting their community and providing care services to the underserved. Due to this, they may experience financial issues at uncertain times. When budgetary resources are strained, it is critical for an FQHC to

operate with maximum operational efficiency
preserve financial security
maintain staffing levels to continue operations

Inefficient and improper business processes will lead to patient dissatisfaction which will result in patients leaving the practice. FQHCs must concentrate on

Maximizing their business and staff efficiency
Minimizing financial risks

How can FQHCs improve operational efficiency and increase revenue?

FQHCs can improve business effectiveness and operational efficiency by making sure they follow these essentials steps.

1. Web portal for patients

It is important for FQHCs to take good care of their patients. Factors such as waiting time, improper schedules, referring to the wrong provider, etc create patient dissatisfaction. In order to prevent these, FQHCs should implement a web portal for their patients. Using the web portal, patients can access their health records, appointment schedules and choose providers based on their interests and preferences. When patients have the liberty to choose providers whom they can be referred to and also the appointment slot, they will show up for the appointments. Through this way, FQHCs can reduce patient-show rates, decrease referral leakage and also improve patient satisfaction.

2. Using technology

FQHCs prefer working with EMR/EHR systems because they are comfortable with it. So they do not wish to move out their EHR/EMR system. An EHR/EMR system has many advantages but when it is complemented with a Referral Management software practices can experience many more benefits.

How great it would be if a Patient Referral Management software could integrate seamlessly with an EMR/EHR system? It can help in ensuring end-to-end Patient Referral Management without disturbing the existing system.

HealthViewX Patient Referral Management solution provides easy steps to integrate with a practice’s EMR/EHR system. The patient demographics, diagnostic reports, test results or any sensitive information can be transferred safely. The solution is HIPAA-compliant with complete data security.

3. Improving staff behaviour

FQHCs must make sure that the people operating their front desk are friendly enough to deal with customers irrespective of their class status or bank balance. The more welcoming they are, the more the patients will feel comfortable and at ease.

Moreover, operational efficiency is the key to success. The more efficient the front desk operations team is at an FQHC, the more practice revenue the FQHC can generate. It can also help them facilitate additional patient visits; which mean that if more patients are adjusted and facilitated, the FQHC has the potential to make more money.

HealthViewX Referral Management Solution to aid FQHCs

HealthViewX Patient Referral Management Solution has the following features that aid FQHCs in improving their operational efficiency and referral workflow.

Outbound Referrals – HealthViewX Referral Management Solution can integrate with both the receiving and referring end. For inbound referrals, it helps in channelizing various sources into one single queue. In case of outbound referrals, it facilitates integration with the existing system to read the patient data and send out referrals.
Referral Timeline – In HealthViewX Referral Management System, any referral has a timeline, to capture and notify the progress of the referral to all the stakeholders. A referral will be mapped to a status which helps in tracking it better. With this, the providers can always be aware of how the referral is progressing.
Workflow and Task Management – A workflow can be defined on how the referral flow must be(business rules). Tasks can be created to manage referrals by assigning it to the respective person.
Improved communication – HealthViewX Referral Management Solution supports messaging and calling features for the referring and the receiving providers to stay connected.
Data Management – The solution is HIPAA compliant and enables secure data exchange of all patient-related documents.
Seamless Integration – The solution can seamlessly integrate with any EMR/EHR/RIS or Third Party application thus providing minimal disruption in the existing referral flow.
Referral History Consolidation – The consolidated data regarding the referrals and the referral history of any patient can be printed as a hard copy at any time in pdf/excel.
Smart Search – HealthViewX Referral Management solution has a smart search facility that helps in finding the right provider for the treatment required.
Referral Data Analytics – Referral data-centric dashboard gives complete data regarding the number of referrals flowing out, the number of referrals in various status, patient follow-ups, etc.

Having Trouble Maximizing And Managing Revenue?

Are you an FQHC facing difficulties in managing your business operations and workflow? Then you may have a revenue cycle problem. HealthViewX Patient Referral Management Software is custom-made to solve the challenges faced by FQHCs. Schedule a demo to know more about our solution!

How Can Federally Qualified Health Centers Improve Patient Engagement With HealthViewX Patient Referral Management Software?

Patient Referral Program in Federally Qualified Health Centers

FQHCs are high outbound referral setups, meaning they send out numerous referrals. A patient visits the clinic when he/she is suffering from an illness. Depending on the need for specialist examination or additional diagnosis, the PCP might refer the patient to an imaging center for further diagnosis or a specialist practice for advanced treatments.

Most of the FQHCs have a team of referral coordinators or RN’s, LPA’s, MA’s operating across various locations handling the referrals today. This team sends out referrals and ensures effective referral coordination. With the help of the patient demographics and diagnosis details available from the referral order, the referral coordinator does the insurance preauthorization and finds the right imaging center or specialty practice for the patient. Following that, the coordinator creates a referral that includes the details of patient demographics and the required diagnosis. Then the referral is sent to the relevant imaging center or specialty practice.

What factors plague the traditional referral process?

The traditional patient referral process in FQHCs are riddled with flaws. The primary shortcomings of the process are improper communication and the far-reaching consequences of follow-ups. Let us consider the following stats,

According to the Archives of Internal Medicine, only half of the referrals result in a completed appointment.
An Archives of Internal Medicine study shows that PCPs do not receive consult reports from the receiving providers about 40% of the time.
The Journal of General Internal Medicine found that 68% of specialists receive no information from the PCP prior to referral visits.
The Journal of General Internal Medicine found that 63% of PCPs and 35% of specialists were dissatisfied with the current referral process
An MGMA study found that 53% of Appointments with more than three weeks of lead time resulted in a no-show

Given these statistics, it is fair to conclude that PCPs are not satisfied with the existing referral program in Federally Qualified Health Centers.

Challenges in the existing referral workflow

The following are the most common problems faced by Federally Qualified Health Centers. Let us consider the challenges with a typical referral scenario to understand it better.

Finding the right specialist/imaging center – Due to the increasing amount of imaging centers and specialists, it takes a lot of time and effort for the referral coordinator to narrow down the referral coordinator’s search and find the right one. It is also less likely for an FQHC to have the updated list of imaging centers and specialty practices.
Insurance pre-authorization – The referral coordinator must check the pre-authorization requirements, health plans, etc. They must retrieve patient-specific data like the history of medications, medical diagnosis and insurance coverage. They must then send it to the insurance company to validate these records. This exhaustive process increases the burden for the referral coordination team.
Time Spent – As referrals are handled manually, a referring coordinator spends approximately half-an-hour to one-hour for creating a referral and even more time in following up.
Tracking the referral – Specialists are usually busy and do not have the time to inform physicians about the progress of referrals. This causes physicians to lose track of referrals. They get no information about appointments, referral loop closure, or feedback from specialists or patients.

Improve Patient Referral Workflow with HealthViewX Patient Referral Management

As per the report from the Journal of General Internal Medicine, referrals managed electronically are twice as likely to result in better referral adherence. This proves that web-based referral management optimizes patient satisfaction and care. HealthViewX has thoroughly analyzed the workflow of FQHCs. We have implemented the following features for many of our FQHC clients thus positively impacting their workflow.

EMR/EHR integration – Our System integrates directly with electronic health records (EHRs). This enables healthcare professionals to easily obtain prior authorizations in real-time at the point of care. It also eliminates time-consuming paper forms, faxes, and phone calls.
Insurance pre-authorization automation – There are two ways in which HealthViewX solution automates the insurance pre-authorization process. The first one is the API-based method. Through this, we retrieve information regarding the forms and communicate information back and forth between the FQHC and the insurance company. The second one is the Form Automation method. Through this, we get all payer-specific forms, fill in the necessary information and send it to the insurance company via e-fax.
Intelligent Provider Match – The system has a smart search feature that enables PCPs to filter receiving providers according to their preferences. The list is always up to date with the newly added specialty and imaging centers which makes it easy for the PCP.
To and fro Communication – The PCP and the center can communicate with the help of the inbuilt secure messaging and voice call applications at any time of the referral process. This allows physicians to get referral updates easily.
Referral Analytics – Customizable dashboards and reports provide information about the number of referrals sent, referrals in various statuses, referrals that were missed, processed and pending. It gives a clear picture for the FQHC and helps them in making informed decisions.

Web-Based Referrals Encourage Patients to Engage With Your FQHC

Patients can use electronic resources within HealthViewX Patient Referral Management System to contact providers regarding questions or concerns. This feature

minimizes unnecessary visits and re-referrals
improves provider availability for other patients who need an in-person appointment.

Electronic referrals also enable PCPs to spend less time on administrative tasks, giving them more time to engage with their patients. Web-based referral management improves accountability and patient satisfaction while reducing costs, allowing providers to effectively close gaps in healthcare.

Automating referrals and related processes enables practices to eliminate 70% of tedious administrative duties so they can focus on improving care delivery. Patients are more likely to schedule and keep appointments when physicians are consistently available and receive accurate patient information to provide optimal care.

Reference

https://www.mgma.com/getattachment/Products/Products/Maximizing-Patient-Access-and-Scheduling/PatientAccessSchedulingResearchReport-INTER_FINAL.PDF.aspx

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495590/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4553012/

4 Ideas To Improve Your Patient Referral Process In 2019

Patient Referral Program in hospitals

An effective patient referral system plays an important role in large enterprise hospitals, specialty hospitals and health systems. It is an integral way of ensuring the patients receive optimal care at the right time by the right care providers.

Unfortunately, like a chain, a patient referral process is only as strong as its weakest link. Often referral systems are weakened by the use of old-fashioned fax machines to process referrals. It compromises the system and creates hazzles for providers and patients to navigate. This reasons why only 54% of referrals result in a completed appointment.

With focused efforts and the right resources, it is possible to enhance the existing referral process and make it more efficient and timely. The referral process must improve office practices and increase patient satisfaction and referral compliance.

Most common problem

Majority of healthcare providers experience major issues related to coordination or communication between relevant departments in their referral systems. These issues tend to have a bad impact on patient satisfaction, clinical care and outcomes.

For instance, according to the Journal of General Internal Medicine, more than two-thirds (68%) of specialists receive no information from primary care physicians (PCPs) prior to referral visits. According to the Archives of Internal Medicine, an astounding 40% of PCPs do not receive consult reports back from specialists following referrals.

Any referral inbound-heavy healthcare system would have faced the above issues. These issues would jeopardize an organization’s reputation, revenue streams and professional relationships. Referrals in inbound-heavy healthcare systems were often mishandled or dropped altogether, forcing referring providers, patients or their representatives to intercede and quarterback the referral process themselves.

It is recommended that such inbound-heavy healthcare systems require a standardized, enterprise-wide process for handling referrals. The healthcare system needs a better solution to support referring providers’ needs, which would significantly improve the handling of incoming patient referrals.

4 Ideas to Improve Patient Referral Process

The following steps can be used by any referral inbound-heavy healthcare organization interested in improving their referral process,

1. Identifying the current and desired state

Before defining what is needed for a desired future state, any healthcare organization must first review and assess their current state. The healthcare system must create a team to determine

How the current referral system works
How the current referral system is not fully competent
Where and how the existing referral process requires changes
Who would be handling such changes
What next steps are needed

Now the healthcare system can achieve the desired future state with ease as the current state is clear.

2. Charting the desired future course

The next action would be to chart and determine the various referral handling scenarios. These scenarios should range from the seemingly simple, such as a referral to an orthopedic specialist for a fractured limb, to the more complicated ones, such as the referral of a patient with multiple complex chronic illnesses. All possible types of referrals must be accounted for, to ensure that they would be handled appropriately and consistently.

3. Shifting to electronic referrals

Healthcare systems who receive referrals are heavily reliant on fax-based referral systems. These systems require staffers to manually re-enter referrals is time-consuming, error-prone and a major bottleneck. Instead, healthcare systems must receive referrals in electronic forms. Electronic referrals save time for staffers, less prone to errors and are also easy to manage.

4. Creating a new standardized process

The team should then create a new, standardized process for inbound referrals and leverage the referral benefits offered by electronic channels of referrals. Critically, this should include plans for internally training their staff members on this new process. It will also overcome referring providers’ previous impressions of the healthcare system mishandling patient referrals.

You Can Too!

By following the steps listed above, it is possible to see improved referral-handling within just a few months. More importantly a healthcare system must invest on the right provider portal like HealthViewX.

It will provider tremendous improvement in return on investment. Patient satisfaction will improve with easier and more efficient access to quality care. And physicians and staff will no longer need to engage in time-consuming and costly rework, data entry and investigations simply to ensure that referrals are correctly processed. A true win/win for all!

Reference

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2686771/