FQHC Revenue Cycle Management Software | AI RCM Platform

Federally Qualified Health Centers face unique financial pressures that private practices don't encounter. Your mission to serve all patients—regardless of ability to pay—creates complex revenue challenges that require specialized solutions, not generic RCM tools.

The FQHC Revenue Cycle Reality

Unlike private practices, FQHCs operate in an environment where:

90% of patients have incomes at or below 200% of the Federal Poverty Level
18% of patients remain uninsured, requiring sliding fee scale administration
49% of revenue comes from Medicaid with complex state-specific PPS rules
Reimbursement covers only 82% of the actual cost of care

These realities create structural challenges that demand specialized expertise and technology-driven solutions.

Critical FQHC Revenue Cycle Challenges

1. Wrap-Around Payment Complexity

The dual-claim process for managed care patients creates significant administrative burden:

Manual reconciliation of MCO payments vs. PPS rates
Payment delays of 4+ months from state agencies
Lost revenue from missed wrap-around submissions
Complex tracking across multiple payers and states

2. Same-Day Integrated Care Coding

Your integrated medical and behavioral health model creates complex billing scenarios:

50% revenue forfeit when second encounters aren't billed
Coding errors from lack of FQHC-specific expertise
Incorrect modifier usage leading to claim bundling
Provider confusion about billable encounter rules

3. Proactive Denial Prevention

Understaffed teams trapped in reactive denial management:

High staff turnover and recruitment challenges
Recurring denials from the same root causes
No visibility into systemic billing patterns
Administrative overload preventing process improvements

Revedy's FQHC-Specific Solutions

Automated Wrap-Around Payment Management

Our AI-powered platform transforms the complex wrap-around process:

Automatic calculation of precise wrap-around amounts
Automated submission to state agencies and MACs
Real-time tracking and follow-up
Complete audit trails for compliance

Result: Capture 100% of entitled PPS revenue with reduced administrative burden.

AI-Powered Same-Day Coding Intelligence

Our agentic coding framework maximizes integrated care revenue:

Documentation analysis to identify billable encounters
Automatic modifier application (59, 25) for separate billing
ICD-10 conflict detection and resolution
Carrier-specific rule enforcement

Result: Maximize revenue from every integrated care visit while ensuring compliance.

Root Cause Analytics and Prevention

Shift from reactive firefighting to proactive revenue integrity:

Multi-dimensional denial categorization by root cause
Payer-specific pattern recognition
Provider performance analytics
Automated improvement recommendations

Result: Systematically reduce denial rates and free staff for high-value work.

FQHC-Specific Platform Capabilities

PPS Rate Optimization

Comprehensive analytics to support Medicaid Change-in-Scope (CIS) applications:

E/M code distribution trending
Service complexity analysis
New service line documentation
State-specific CIS application support

Sliding Fee Scale Integration

Automated compliance with HRSA requirements:

FPL-based discount calculations
Income verification tracking
Compliance audit trails
UDS reporting integration

340B Program Support

Specialized tracking for this critical funding stream:

Patient eligibility verification
Prescription tracking and reconciliation
Savings calculation and reporting
Audit preparation and compliance

HRSA Compliance Monitoring

Continuous oversight for regulatory adherence:

UDS data quality assurance
Board governance reporting
Financial management compliance
OSV preparation support

EHR Integration for FQHCs

Revedy integrates seamlessly with the EHR and practice management systems most commonly used by FQHCs:

Supported FQHC EHR Systems

eClinicalWorks - Direct integration with billing module
NextGen Healthcare - Real-time encounter data sync
Athena Health - Automated coding workflow
Epic (Community Connect) - API-based integration
Greenway Health - Bi-directional data flow
OCHIN EPIC - Specialized FQHC network support

Integration Features

Real-time data synchronization ensures your coding happens as encounters are documented, not days later. This accelerates cash flow and reduces the risk of missed billings.

Automated data validation checks for common FQHC billing errors before claims leave your system—preventing denials rather than appealing them later.

Minimal workflow disruption means your providers and billing staff continue using familiar tools. Revedy works in the background, enhancing accuracy without adding steps.

Implementation Process

Most FQHC integrations are completed within 2-3 weeks:

Week 1: API configuration and initial data mapping
Week 2: Pilot testing with sample encounters
Week 3: Full deployment and staff training

No lengthy downtime. No data migration headaches. Just enhanced revenue cycle performance.

The FQHC ROI Framework

For FQHCs, revenue cycle optimization delivers returns across three critical domains:

Financial Stability

Maximize PPS reimbursement through comprehensive revenue capture
Accelerate cash flow with automated processes
Reduce revenue leakage from preventable errors

Compliance Assurance

HRSA requirement adherence with specialized expertise
Audit preparation and documentation
Risk mitigation from regulatory violations

Mission Focus

Reduce administrative burden on clinical staff
Eliminate manual processes that divert resources
Enable patient-focused care delivery

Real Results from Community Health Centers

FQHCs using Revedy's AI-powered revenue cycle platform report significant improvements across key performance indicators:

Revenue Capture

15-25% increase in wrap-around payment recovery
$75,000-$150,000 in annual recovered revenue (typical 15-provider FQHC)
12-18 days reduction in days in accounts receivable
8-12% decrease in net collection rate leakage

Operational Efficiency

40-60% reduction in manual coding time per encounter
3-5 hours saved per week on wrap-around payment reconciliation
30-50% fewer preventable denials requiring rework
2-3 FTE equivalents freed for higher-value activities

Compliance & Risk Mitigation

90%+ reduction in coding errors flagged during audits
100% compliant same-day billing for integrated care
Complete audit trails for HRSA site visits
Proactive alerts for regulatory changes affecting billing

Case Study: Rural FQHC in the Southeast

A 22-provider FQHC serving 18,000 patients annually implemented Revedy to address recurring wrap-around payment gaps and same-day billing errors.

Results after 6 months:

Recovered $127,000 in previously missed wrap-around payments
Increased same-day visit billing by 23%
Reduced overall denial rate from 8.2% to 4.6%
Eliminated manual wrap-around tracking (previously 6 hours/week)

Read the full case study →

Why Generic RCM Solutions Fall Short for FQHCs

Standard revenue cycle management tools are designed for fee-for-service private practices, not the unique FQHC environment:

No PPS expertise for encounter-based billing
Limited managed care reconciliation capabilities
Generic denial management without FQHC-specific patterns
No regulatory compliance features for HRSA requirements

Implementation and Partnership

Our FQHC implementation process is designed for minimal disruption:

Phase 1: Assessment and Configuration

Current state analysis of your revenue cycle
FQHC-specific configuration of our platform
Integration with your existing EHR and practice management systems

Phase 2: Pilot and Validation

Controlled pilot with select patient encounters
Validation of coding accuracy and compliance
Staff training on new workflows

Phase 3: Full Deployment

Complete rollout across all service lines
Ongoing monitoring and optimization
Continuous compliance assurance

The Strategic Imperative

The margin squeeze facing FQHCs isn't temporary—it's structural. Federal grant funding hasn't kept pace with inflation, PPS rates often fail to cover true costs, and administrative complexity continues to grow.

Success requires a fundamental shift: from reactive, manual revenue cycle management to proactive, automated revenue integrity. This transformation isn't just about capturing more dollars—it's about ensuring the financial stability needed to fulfill your mission of serving vulnerable populations.

Ready to Transform Your FQHC Revenue Cycle?

Our specialized team understands the unique challenges you face and the regulatory environment you navigate.

Contact us today to see how our platform can:

Automate your wrap-around payment process
Optimize same-day integrated care billing
Provide the analytics needed for CIS applications
Ensure continuous HRSA compliance

Your mission is too important to let revenue cycle inefficiencies undermine it. Let us handle the complexity so you can focus on caring for your community.

Frequently Asked Questions About FQHC Revenue Cycle Management

What makes FQHC billing different from private practice billing?

FQHCs use encounter-based Prospective Payment System (PPS) rates rather than fee-for-service billing. This means you receive a single payment per qualifying visit regardless of services provided, with complex wrap-around payment processes for managed care patients. Standard RCM tools aren't designed for this model.

How does Revedy handle wrap-around payments?

Our platform automatically calculates the difference between managed care plan payments and your PPS rate, generates the wrap-around claim, submits it to the appropriate state agency or MAC, and tracks payment status. This eliminates manual reconciliation and ensures you capture 100% of entitled reimbursement.

Can Revedy help with our UDS reporting?

Yes. While Revedy focuses on revenue cycle optimization, our accurate coding and billing data directly supports your UDS reporting requirements. Clean data means more accurate Line 9B (revenue) reporting and better documentation for financial management metrics.

What about 340B program compliance?

Revedy includes specialized tracking to ensure 340B-eligible prescriptions are properly identified and recorded. This supports both your savings calculations and audit preparation, though you'll want to pair this with a dedicated 340B platform for comprehensive program management.

How long does implementation take for an FQHC?

Most FQHC implementations are completed within 4-6 weeks from contract signing to full deployment. This includes EHR integration, staff training, pilot testing, and validation. We work around your operational calendar to minimize disruption during busy periods.

Do you have experience with state-specific Medicaid rules?

Yes. Our platform includes state-specific PPS rate configurations, managed care wrap-around procedures, and Medicaid billing requirements for all 50 states. We stay current with state Medicaid plan changes so you don't have to.

What kind of support do you provide after implementation?

Every FQHC client receives dedicated support including: a named account manager familiar with FQHC operations, priority technical support, quarterly business reviews, and proactive alerts about regulatory changes affecting your billing.

How do you handle same-day integrated care visits?

Our AI coding engine analyzes encounter documentation to identify when separate medical and behavioral health services qualify for independent billing under the "significant and separately identifiable" standard. It automatically applies appropriate modifiers and ensures compliance with payer-specific policies.