As Operational Site Visits (OSVs) resume virtually, it is important for Community Health Centers to maintain continuous compliance. Compliatric is excited to continue their “Compliance Webinar Series” where each month, program requirements are reviewed to assist health centers in understanding various elements. Participants will be able to utilize these webinars to increase their knowledge of the requirements, and also take compliance to the next level. This month’s webinar will focus on the following chapter: Chapter 16: Billing and Collections Webinar attendee takeaways will include: · Understanding the requirements and why they are important · Methods to maintain continuous compliance (without addressing it last minute or only during an OSV) · How to use the requirement in everyday practice to improve your Community Health Center

1. www.compliantfqhc.com
Continuous Compliance Series- It’s not JUST an OSV Prep
COMPLIATRIC WEBINAR SERIES
Presented by: Cecelia Creighton, MA
www.ckfinances.com

2. Presenter
Cecelia Creighton
Dba CK Financial Services
www.ckfinances.com

3. Disclaimers:
❖ CK Financial Services presentation is not endorsed by Management Strategists Consulting
Group (MSCG)
❖ CK Financial Services presentation is not endorsed by Health Resources Services
Administration (HRSA) or the Bureau of Primary Health Care (BPHC).
❖ CK Financial Services is not employed by MSCG or BPHC
❖ Independent consultant who is contracted to conduct Operational Site Visits (OSV),
provide technical assistance, and assist health centers with preparation for their OSV
❖ This information should not be considered legal advice
Confidentiality Notice: This document is confidential and contains proprietary information and intellectual property
of CK Financial Services. Neither this document nor any of the information contained herein may be
reproduced or disclosed under any circumstances without the express written permission of the aforementioned

4. A Salute To You!

5. ❖Chapter 16 (Billing and Collections) – Overview- Meeting Compliance
❖Chapter 16 (Billing and Collections) Review of 10 elements (a. – j.)
❖Chapter 16 (Billing and Collections) Sample Waiver Policy/Procedures
❖Chapter 16 (Billing and Collections) Sample Refusal to Pay Policy/Procedures
❖An “Open Book Test” HRSA Consolidated Checklist
❖Resources
❖Questions
❖Contact Information
Agenda Focus

6. ❖Participants will be able to:
❖Understand the requirements and why they are important
❖Develop methods to maintain continuous compliance (without doing it last
minute or only during an OSV)
❖Learn how to use the requirements in everyday practice to improve your
Community Health Center
Lesson objectives

7. Chapter 16: Billing and Collections
Meeting Requirements (element a)
❖ The health center has a fee schedule for services that are within the HRSA-approved scope
of project and are typically billed for in the local health care market. (element a)
✓ Are there current fee schedules for each service area: 1) medical fee schedule, 2) dental fee
schedule, and 3) behavioral health fee schedule (in-house lab/x-ray fee schedules and
procedures fee listing). (Board approved)
✓ Are the fee schedules reflected on Form 5A for required and additional services
✓ Interviews conducted with CFO/financial or billing staff (provides clarity and
explanations as needed)

8. Chapter 16: Billing and Collections
Meeting Requirements (element b)
❖ The center uses data on local prevailing rates and actual health center costs to develop
and update its fee schedule. (element b)
✓ Has an analysis been conducted to support setting fees (examples: Medicare rates, Blue
Cross/Blue Shield, UDS report, National Fee Analyzer)
Note: Services (for example, transportation, translation, other non-clinical services) on Form
5A that are not billed for in the health care market may be excluded from the health center’s
fee schedule

9. Chapter 16:- Billing and Collections - (element c)
❖ Does the health center participate in Medicaid, CHIP, Medicare, other public or private
assistance programs. (element c)
✓ List of provider billing numbers: NPI (national provider identifier, DEA (drug enforcement
agency #), PTAN (provider transaction access number assigned upon enrollment with
Medicare), State Medicaid #, State License #, and EIN (employer identification #), or SSN)
✓ List of program site billing number (per Form 5B (sites) or any other documentation of
participation in Medicaid, CHIP and Medicare) (continued…………..)

10. Chapter 16:- Billing and Collections - Cont. (element c)
❖Does the health center participate in Medicaid, CHIP, Medicare, other public or
private assistance programs. (element c)
✓ List of commercial private insurance plans (medical and dental) – (third party
payors)
✓ Other documentation (if applicable) of participation in other public or private
program or health insurance plans (State Medicaid Expansion Program)

11. Chapter 16:- Billing and Collections - (element d)
❖ Does the health center have systems, which may include operating procedures, for billing and
collections. (element d)
✓ Billing and Collections Policy and Procedures (Header) (Date Board Approved)
✓ Educating patients on insurance and, if applicable, related third-party coverage options available
✓ Process for billing Medicare, Medicaid, CHIP, and other public and private commercial insurance plans
in a timely manner (electronic health records system that is used)
✓ Process for requesting payments from patients, while ensuring that no patient is denied service based
on inability to pay (continued………………)

12. Chapter 16: Billing and Collections
Meeting Requirements – Cont. (element d)
❖ Does the health center have systems, which may include operating procedures, for billing and collections.
✓ Provision(s) to waive or reduce fees owed by patients
✓ Refusal to pay policy (as applicable) Board elects to have this policy
✓ Procedures for notifying patients of additional costs for supplies and equipment related to, but not included in, the
service: Note: Examples of additional costs – prescription drugs/medications, eyeglasses, dentures, etc.)
✓ Registration, (completed forms/signed by patient), Eligibility (State Medicaid Plans, etc.), Outreach (enabling staff)
and Enrollment Procedures
✓ Revenue Cycle Metrics: collection ratios, bad debt write off as % of total billing, collections per visit, charges per
visits, % AR less than 120 days - days in AR
✓ Outsourced billing company, (if applicable) review contract for fee arrangement and duties to be performed for
health center

13. Chapter 16: Billing and Collections
Meeting Requirements – (element e)
❖ Health center elects to offer additional billing options or payment options (element e)
✓ Does health center offer payment plan methods, grace periods, prompt or cash payment
incentives (Example 10% discount for payment in full)
✓ Do health center operating procedures for implementing these options address methods to
ensure accessibility to “All” patients regardless of income level or sliding fee discount pay
class

14. Chapter 16: Billing and Collections Requirements (element f)
❖ Health center has billing records – Timely and Accurate Third- Party Billing
✓ Comparison of initial billing dates to service dates is reviewed (are claims submitted within 14 business
days from date of service), (explanation for claim submission greater than 14 days, i.e., scrub claims, etc.)
✓ 1) Sample of 5 billing records each for patient visits from across at least 3 unique services (primary care,
preventative dental, OB, behavioral health). 2) Sample of 5 charge records each - billing and payment
requested from patients 1) SFDP under insured (insurance plan does not cover all services) & 2) patients not
eligible for SFDP (over 200% FPG) & 3) insured (third-party) - (primary care, preventative dental, OB, behavioral
health). (compare what is billed to fee schedules)
✓ Review of third-party billing procedures to ensure timely claim submission to third-party payors
✓ An interview with CFO and staff involved in the billing and collections process
✓ Documentation of rejected claims - re-worked/corrected and resubmitted Note (suspended payments may
occur, Medicaid, Medicare, third-party)

15. Chapter 16: Billing and Collections Requirements (element g)
❖ Health Center Has Billing Records or Other Forms of Documentation That Reflect for Accurate Patient Billing
(element g)
✓ Charges patients in accordance with the health center’s fee schedule (medical, dental, behavioral health) if applicable
the sliding fee discount
✓ Correct discounts are applied to charges
✓ Makes reasonable efforts to collect such amounts/charges owed from patients, co-pays, nominal charges, or
discounted fees
✓ Sends billing statement monthly for outstanding balances, make phone calls, etc. (health centers are not “free” clinics)

16. Chapter 16: Billing and Collections – Requirement (element h)
❖ Health Center Has Board–Approved Policies or Procedures for Waiving or Reducing Fees (element h)
✓ Policies and procedures that contain provision(s) to waive or reduce fees owed by patients based on patient’s
inability to pay
✓ Specific circumstances and criteria to warrant fee waiver and reduction (financial hardship - loss of employment,
loss of job, illness, etc.)
✓ Formal Waiver Request Form, (time period: at one clinic visit, for one month, etc.) authorized staff to approve/deny
✓ Sample of two or three billing records where patient fees were waived or reduced

17. Chapter 16: Billing and Collections – Requirement Cont. (element h)
❖ Sample Waiver Policy and Procedures (element h)
✓ Sample of two to three billing records where patient fees were waived or reduced
Sample Waiver Policy
Purpose:
The purpose of the policy is to define request for waiver and/or reduction of patient payment of clinic visit(s). An example may be based
on reason for hardship to patient and/or his/her family. Include the date of the request and include any supporting documentation to
justify the request.
Examples to consider for waiver/reduction of fees:
• Death of wage-earner in family.
• Wage-earner in the family loses employment.
• Loss of housing.
• Extended illness in the immediate family, et.al.
Authorized Personnel:
• CFO & CEO: review and approve/deny waiver request, inform patient in writing of the clinic’s decision.
• Waiver Time Period: 1) one clinic visit, or 2) 30 days, or 3) six-months, etc.
• Once a waiver has been approved it will be communicated to billing office and noted on the patient’s account.
 Refer to Health Center Compliance Manual- Chapter 16- Billing and Collections, Element h.

18. Chapter 16: Billing and Collections – Requirement (element i)
❖ Does the health center provide supplies or equipment that are related/not included in the
service (element i)
✓ Note: supplies and equipment are included in a service as part of prevailing standards of
care/reflected in the fee schedule (casting materials, bandages)
✓ Charges patients for eyeglasses, prescription drugs, dentures, etc. (yes or no)
✓ How are patients notified about out-of-pocket costs for these supplies and equipment, in advance
of service provision, for example, posting in clinic exam rooms, clinic service brochures, website,
or face to face (enabling staff informs patients)

19. Chapter 16: Billing and Collections – As Applicable (element j)
❖ Does The Health Center Have A Refusal to Pay Policy (element j)
✓ Board-approved policy for election to limit or deny services based on a patient’s refusal to pay, distinguish between
refusal/inability to pay
❖ Notify patients amount owed/time permitted to make payments, collection efforts: meet with financial counselor,
establish payment plan
✓ How will services be limited or denied and when is it determined that the patient has refused to pay (see Sample
Refusal to Pay Policy)
✓ Consideration- the health center determines how and when such patients may be permitted to rejoin the practice

20. Chapter 16: Billing and Collections – As Applicable (element j)
Sample Refusal To Pay Policy (element j)
❖ Documentation of cases where health center has applied its refusal to pay policy within the past 2 years (if applicable)
Sample Refusal to Pay Policy
Purpose:
The purpose of the policy is to address processes for patients who refuse to pay for their clinical services. This policy distinguishes between
inability to pay and refusal to pay.
 Example: Refusal to Pay- Patient “A”, was rendered medical care and refused to pay for their outstanding clinic charges. “Unwilling to pay”.
 Example: Inability to Pay- Patient “B”, was rendered medical care and is willing to pay for clinic visits, however, does not have finances to pay
for outstanding clinic charge(s).
Procedures:
• Inform patients of their responsibility to pay for clinical services that were rendered to them.
• Inform patients by telephone, and/or letter of Clinic’s payment plan provisions.
• Notify patients that past due amounts are taken to collection agency/in house collections.
• Inform patients that non-emergent clinic services may be denied, as determined by provider.
• If the health center limits or denies services based on refusal to pay, the health center determines how and when such patients may be
permitted to rejoin the practice, Chapter 16 – Billing and Collections. (Health Center Program Compliance Manual)

21. Consolidated Documents Checklist by Program Requirements
“An Open Book Test”
Per HRSA’s Health Center Program Compliance Manual:
19-Health Center Program Requirements (93 elements: 88 assessed on-site during OSV)
Is the health center able to provide requested documents, i.e., materials to support elements for
Chapter 16 - Billing and Collections, if so, you most likely meet “Compliance”.

22. Resources
❖ www.compliatric.com
❖ HRSA Health Center Compliance Manual – Bureau of Primary Health Care (hrsa.gov)
❖ Health Center Program Site Visit Protocol – Bureau of Primary Health Care (hrsa.gov) (updates May 27, 2021)
❖ Health Center Program Site Visit Protocol: Sampling Review Resource Guide – Bureau of Primary Health Care
(hrsa.gov) Plus: Naming Convention for OSVs
❖ https://www.healthcenterinfo.org/
❖ www.caqh.org – on-line data repository of credentialing data, process of practitioner’s self reporting
demographic, education and training, work history, and other credentialing profile for insurance companies to
access

23. Questions?

24. Contact Information
Cecelia Creighton
Dba CK Financial Services
www.ckfinances.com
Direct # 402.612.4049