This resource is part of the AMA's Debunking Regulatory Myths series, supporting AMA's practice transformation efforts to provide physicians and their care teams with resources to reduce guesswork and administrative burdens.
Debunking the myth
Federally qualified health centers (FQHCs) may bill for more than one visit for the same patient on the same day. FQHCs are paid based on either an all-inclusive rate (AIR) per patient visit or the Medicare Prospective Payment System (PPS).
An FQHC physician or non-physician provider paid based on the AIR may bill for more than one medically necessary face-to-face visit in the same day under any one of four circumstances:
- When a patient has an annual wellness visit (AWV) or initial preventive physical examination (IPPE) and a separate qualified medical and/or mental health visit within the same day;
- When a patient has a first visit with an FQHC physician or non-physician provider and then requires a second visit to treat an injury or illness later that same day;
- When the patient has a medical visit and a mental health visit on the same day; or
- When a patient has a diabetes self-management training or medical nutrition therapy on the same day as a payable medical visit.1
An FQHC physician or non-physician provider paid based on the PPS may bill for more than one medically necessary face-to-face visit in the same day:
- When the patient suffers an illness or injury that requires additional diagnosis or treatment after a first visit earlier in the same day; or
- When the patient has a medical visit and mental health visit on the same day.1,2
Background
A lack of clarity and awareness exists around circumstances in which FQHCs can bill for more than one visit on the same day for the same patient. This confusion can create unnecessary burdens for both physicians and patients.
Such burdens include physicians performing services they are not reimbursed for, and patients being required to schedule and return for a separate visit on a different day to address an existing health concern. Ensuring that FQHCs consider this information when billing for patient visits can save patients time, improve patient outcomes, and ensure physicians are paid appropriately for the care they provide.1
AMA policy
Resources
- Rural Health Clinic/Federally Qualified Health Centers Medicare Claims Processing Manual Chapter. Accessed July 2024.
- Download this myth: Double billing at federally qualified health centers (FQHCs) (PDF)
References
- Centers for Medicare & Medicaid Services. Chapter 9: Rural Health Clinic/Federally Qualified Health Centers. Medicare Claims Processing Manual. Published June 7, 2023. Accessed July 2, 2024. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c09.pdf
- Centers for Medicare & Medicaid Services. Frequently Asked Questions on the Medicare FQHC PPS. Published November 21, 2019. Accessed August 8, 2024. https://www.cms.gov/medicare/medicare-fee-for-service-payment/fqhcpps/downloads/fqhc-pps-faqs.pdf
Debunking Regulatory Myths overview
Visit the overview page for information on additional myths.
Disclaimer: The AMA's Debunking Regulatory Myths (DRM) series is intended to convey general information only, based on guidance issued by applicable regulatory agencies, and not to provide legal advice or opinions. The contents within DRM should not be construed as, and should not be relied upon for, legal advice in any particular circumstance or fact situation. An attorney should be contacted for advice on specific legal issues. Additionally, all applicable laws and accreditation standards should be considered when applying information to your own practice.
