In most cases, the special setup for Health Centers applies only to Medicare and Medicaid. This includes Managed Care programs for Medicare and Medicaid which are often considered to be commercial payers.
Blue Cross Blue Shield and Commercial payers typically bill as Fee-for-Service on a 1500 claim form just like at other private practices. No special setup is required for these payers. However, every state has potential for exceptions. Therefore, any payer can be setup for encounter rate or roll-up billing if needed.
- Encounter Rate Billing: This is an option for payers such as Medicare (FQHC / RHC) and Medicaid that have unique and specific billing and claim requirements, and that reimburse at a flat encounter rate. Encounter Rate Billing provides the ability to automatically adjust charges so that the balance reflects the payer’s expected encounter reimbursement rate/amount. In addition, an encounter rate code required by the payer on claims can be automatically inserted onto each encounter. For example, a 0521 Revenue Code line item may be required on Medicare UB claims, and a T1015 CPT4 Code line item may be required on Medicaid 1500 claims. The setup and configuration of the Encounter Rate Billing library also defines which of the original charge line items on an encounter are included on the claim. FQHC clients must use Encounter Rate Billing for Medicare. It is the only option available that meets CMS’s complex requirements and guidelines for claims.
- Roll-Up Billing: This is an option for payers such as Medicare (RHC only) and Medicaid that have unique and specific billing and claim requirements, and that reimburse at a flat encounter rate. Roll-Up Billing provides the ability to roll-up multiple charges on an encounter into a single line item on the claim. The amount on that line item is equal the total sum of the rolled-up charges. The roll-up can be done by Revenue Code (e.g. 0521) or by CPT4 Code (e.g. T1015).
Sliding Fee Schedules are linked to a patient in NextGen® Enterprise PM. They can also be linked to a specific patient encounter. Once linked, a percentage of the charge amounts entered on an encounter is automatically adjusted off. The percentage of the automatic adjustment is based on household family size and annual income.
Multiple sliding fee schedules can be created if needed. For example, if the percentage discounts vary for medical, dental, vision and/or behavioral health services, separate schedules can be created for each.
