1. FQHCs, RHCs and Accountable Care Organizations: More than Just Claims
Problem Statement: Utilization of claims data for data mining, etc. is the historical
method for meeting measure criteria. However, in the case of community health
centers (otherwise known as Federally Qualified Health Centers – FQHCs and
FQHCLAs) and rural health centers (RHCs), claims data alone will not meet the ACO
needs.
Background:
 FQHCs/ FQHCLAs/ RHCs typically utilize visit-based, all-inclusive rates rather
than service-based codes
 Conditions are mainly tracked for the purposes of grant compliance rather than
services
 The cost of a Medicare visit at an FQHC/ FQHCLA is typically higher than the
reimbursement rate in many markets. Only 7 percent of all Medicare payments
go to FQHCs.1 Combined with the complicated methodology that is required to
submit Medicare claims and not possessing the knowledge to produce ‘hybrid’
repayment methodologies (Medicare plus grants for services), many opt not to
utilize Medicare as a payer.
 Medicaid and Medicare claims are typically ‘wrap-around’ rather than traditional
FFS. Additionally, only certain HCPCS codes are allowed:
 Conditions are typically tracked solely for the purposes of care OR more likely for
the purposes of meeting grant compliance2 (i.e. Ryan White for HIV/ AIDS/ STI,
Ahlers for family planning amongst potentially hundreds of others)3.
 However - starting in 2011 - FQHC claims are required to include HCPCS codes
that identify the specific service provided,
Concern: Historical Data Evaluation I. When evaluating historical data – data for
claims in 2011 will be based upon PPS rather than FFS going forward. The rationale by
HHS is in order to develop a statutorily required prospective payment system for
FQHCs.
All claims prior to 2011 will not necessarily include service HCPCS codes. They will
only contain visit codes. One will not necessarily be able to understand what service
occurred or provider type (physician, PA or NP) actually provided the service.
Both PPS and FFS data will be included. This will also complicate the data/ measure
mining process.
1
Retrieved from http://www.gao.gov/products/GAO-10-576R
2
Retrieved from http://www.hrsa.gov/grants/manage/index.html
3
Retrieved from http://datawarehouse.hrsa.gov/grantsdetail.aspx
1 Federally Qualified Health Centers and Rural Health Centers Partnering with
Accountable Care Organizations: More Than Just Claims
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2. Concern: Historical Data Evaluation I. Limited data from CMS claims (Medicare,
Medicaid or SCHIP) will require review of clinical data from the patient record to attain
the necessary data for measure population.
1) Medicaid billing not used as almost 90% of all services community center are
paid via grants rather than insurance
2) Medicaid and Medicare patients comprise only 37 percent of health center
patients.
3) Individuals who receive services at these types of organizations are typically not
insured.
4) Individuals who receive services at these types of organizations are typically not
insured. Other patient services are paid via grant. Grant compliance in clinic
EMR/EHRs are the primary tracking performed. For example, of a clinic is
paying for a patient receiving services for ‘Family Planning’ – these will be
tracked more
5) Billing for Medicaid and Medicare is different and very cumbersome for these
clinics. These providers’ Medicaid and Medicare claims are paid via enhanced
reimbursement methodology. Most are paid at a visit level – rather than tracking
of a condition under the FQHC of a hierarchy. As such, many clinics choose not
to utilize Medicare and Medicaid unless absolutely necessarily.
Concern: Service and Provider Classification. FQHCs/ FQHCLAs and RHCs submit
claims for encounters for claims and receive payment based on an interim all-inclusive
rate. These claims distinguish general classes of services (for example, clinic visit,
home visit, mental health services) by revenue code, the beneficiary to whom the
service was provided, and other information relevant to determining whether the all-
inclusive rate can be paid for the service. The claims contain very limited information
concerning the individual practitioner, or even the type of health professional (for
example, physician, physician assistant or nurse practitioner) who provided the service.
The list of standard HCSPC service codes are shown in the table below:
HCPCS Definition
Revenue
Code
0521 Clinic visit by member to RHC/ FQHC
0522 Home visit by RHC/FQHC practitioner
0524 Visit by RHC/FQHC practitioner to a member in a covered Part A
stay at a Skilled Nursing Facility (SNF)
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3. 0525 Visit by RHC/FQHC practitioner to a member in a SNF (not in a
covered Part A stay) or NF or ICF MR or other residential facility
0527 RHC/FQHC Visiting Nurse Service(s) to a member’s home when in
a Home Health Shortage Area
0528 Visit by RHC/FQHC practitioner to other non RHC/FQHC site (e.g.,
scene of accident)
Billing and service codes are limited for multiple reasons:
 HCPCS – rather CPT II – are used more often for billing as private insurance is
rarely utilized (Patients with private insurers tend not to visit FQHCs). Conditions
are not tracked very effectively – rather the type of visit as shown in the attached
appendix.
 As services at FQHCS include WIC, SNAP, housing and other services, they all
tend to be integrated in the patient (or client) record, further complicating the
patient record
 Most have not ‘mastered’ the use of extensive hybrid revenue generation (i.e.
Medicare for the disabled, Medicaid waivers for certain populations, SCHIP and
grants integrated).
 The majority of these clinics enter service codes meet the needs of their grants
for compliance (i.e. meet ‘spend down’) purposes rather than billing to a third
party
Applies to:
 Health Information Exchanges (HIEs)
 Accountable Care Organizations (ACOs)
 Any other initiative in which community health care solutions that have FQHCs,
FQHCLAs, RHCs or any provider that utilizes a significant number of grant funds
rather than public or private payers for funding their costs of care
 For ‘scanned’ historical data (OCR), either inform the client of the risks of this
data or increase the cost of data
Accountable Care Organizations (ACOs) and FQHCs
Accountable Care Organizations or ACOs must assess any and all means to collect the
necessary data for Medicare beneficiaries.
3 Federally Qualified Health Centers and Rural Health Centers Partnering with
Accountable Care Organizations: More Than Just Claims
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4. Under the final rule, in order to be able to align beneficiaries with the entities that wish to
participate in the Shared Savings Program, in general we require data that identify all of
the following:
 Services rendered (primary care HCPCS codes)
 Type of practitioner providing the service (that is, a physician, NP, PA, or CNS)
AND
 Physician specialty.
For services billed under the physician fee schedule, these data items are available on
the claims submitted for payment. In contrast, as discussed in the proposed rule,
FQHCs and RHCs submit claims for each encounter with a beneficiary and receive
payment based on an interim all-inclusive rate. These FQHC/RHC claims distinguish
general classes of services (for example, clinic visit, home visit, mental health services)
by revenue code, the beneficiary to whom the service was provided, and other
information relevant to determining whether the all-inclusive rate can be paid for the
service. The claims contain very limited information concerning the individual
practitioner - or even the type of health professional – such as a physician, physician
assistant or nurse practitioner - who provided the service.
As CMS is planning to create a crosswalk for ACOs to meet the needs of these clinics,
organizations must ensure incorporation of all necessary crosswalks into any ACO
solution in order to ensure all data types and conditions are correctly mined and
integrated into the requisite data store/ repository.
Potential Mitigation Strategies:
 Integration of recent HCPCS dictionaries
 Modernize all existing service and revenue codes to meet current CMS
standards
 Add current CMS ‘crosswalks’
 Utilize clinical data mining with context (nomenclature) rather than just code sets
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4 Federally Qualified Health Centers and Rural Health Centers Partnering with
Accountable Care Organizations: More Than Just Claims
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