Key Takeaways
- Medicare patients, including those dually eligible for Medicare and Medi-Cal, are a growing population at California’s Federally Qualified Health Centers.
- Medicare pays health centers differently than Medi-Cal, and understanding these distinct payment rules is essential for health centers to be reimbursed correctly.
- The stronger Medicare billing practices outlined in this publication can help FQHCs’ financial sustainability.
Across California, many people seek care at Federally Qualified Health Centers, commonly known as FQHCs. As Californians continue to age, more Medicare patients are receiving care in FQHCs. These patients include those with both Medicare and Medi-Cal coverage (“dually eligible enrollees”) as well as those with Medicare only.
Since Medicare pays FQHCs differently than Medi-Cal, health centers that understand Medicare’s requirements and improve their contracting, operations, and billing can increase revenues and improve the financial sustainability of caring for this population’s complex needs.
Considerations for Medicare Billing in Federally Qualified Health Centers was created to support FQHCs seeking reimbursement for care provided to Medicare enrollees by providing an overview of basic billing steps. It is divided into four sections based on the different coverage scenarios for Medicare patients:
- Dually eligible enrollees with Original Medicare and Medi-Cal
- Dually eligible enrollees with Medicare Advantage, including D-SNP, and Medi-Cal
- Original Medicare only
- Medicare Advantage plan only
The accompanying Basics on Original Medicare vs. Medicare Advantage highlights key differences related to doctor and hospital choice, cost, and coverage between the two models.
The authors are consultants with Wipfli Advisory, LLC, a national consulting firm providing professional services to FQHCs and other organizations in the health care industry.
