The document outlines an audit checklist for Federally Qualified Health Centers (FQHCs) focusing on billing practices, payer contract management, front office operations, data entry accuracy, claims submission, payment posting, financial sustainability, and staff training. It emphasizes essential processes such as payment collection, insurance verification, billing accuracy, and compliance with HRSA guidelines to improve collections and reduce claim denials. The checklist aims to enhance operational efficiency and ensure that the clinic functions sustainably while complying with regulatory requirements.

1. BCA’s FQHC Billing Audit Checklist
1. Payer Contract Management
Objective: Ensure that the clinic has access to, understands, and correctly
applies payer contract terms and fee schedules for accurate billing and payment
posting.
Contract Availability:
- Does the clinic have easy access to all current payer contracts?
- Are all payer contracts stored in a secure and accessible location?
- Is there a system in place for keeping contracts up to date (e.g., renewals,
changes in rates)?
Fee Schedule Reconciliation:
- Does the clinic have access to the fee schedules for each payer?
- Are payer-specific fee schedules available to billing staff for reference during
claim processing?
- Has the clinic reconciled its billed rates against the payer fee schedules in the
past 12 months?
- Are there discrepancies between the billed amounts and payer allowable
rates, and if so, have these been addressed?
Contract Terms Review:
- Are the clinic's billing and payment posting processes aligned with payer
contract terms?
- Does the clinic adhere to the payer’s timely filing and reimbursement policies?
2. Front Office Operations: Payment and Insurance Verification
Objective: Ensure that the front office staff is trained to correctly handle
insurance verification, calculate patient liability, and collect payments at the time
of service to reduce errors and increase collections.
Payment Collection at Time of Service:
- Does the front office ask for payment at the time of service for copayments,
deductibles, and coinsurance?
- Are there documented processes in place for collecting payments before the
patient leaves the clinic?

2. - Is there a point-of-service payment system available to staff to streamline this
process?
Insurance Verification:
- Does the front office verify insurance eligibility before or at the time of service
for every patient?
- Is patient insurance information validated for accuracy, including payer name,
policy number, group number, and coverage status?
- Are there clear processes in place for re-verifying insurance for patients with
recurring visits or updated insurance?
Patient Liability Calculation:
- Is the front office trained to calculate patient liability accurately based on
copay, coinsurance, or deductible amounts?
- Are patient responsibility amounts correctly calculated and communicated to
patients before or during the visit?
- Is there a system for tracking patient liabilities, including outstanding balances
and what has been collected at the time of service?
Sliding Fee Discount Application:
- Are sliding fee discounts correctly applied for eligible patients based on
income and family size?
- Is the front office trained to explain and apply sliding fee discounts at the time
of service?
- Are sliding fee schedules regularly updated and compliant with HRSA
guidelines?
3. Data Entry Accuracy
Objective: Ensure accurate data entry at the front office to prevent claim denials
due to incorrect patient demographics, insurance information, and service
details.
Patient Demographic Data Entry:
- Are patient demographics, including name, date of birth, address, and contact
information, entered accurately into the EMR system?
- Are there periodic checks for data accuracy, including matching patient
information with payer records?
- Have errors related to data entry been reviewed and corrected in the last
audit period?

3. Insurance Information Entry:
- Is insurance information correctly entered into the billing system, including
payer name, policy number, group number, and coverage details?
- Are payer-specific rules for claims entry followed (e.g., identifying primary vs.
secondary insurance)?
- Is there a process to address data entry errors in insurance information
promptly?
Service Information Entry:
- Are service dates, provider details, and service locations correctly entered into
the billing system?
- Are modifiers used appropriately and entered accurately to support coding?
- Is there a workflow for addressing service data entry issues, such as
mismatched service dates or missing modifiers?
4. Billing Process: Claims Submission and Denial Prevention
Objective: Ensure claims are submitted accurately, timely, and in alignment with
payer contract terms to reduce denials and improve collections.
Claim Accuracy:
- Are claims checked for accuracy before submission, including coding,
modifiers, and documentation to support services provided?
- Are billing codes (CPT, HCPCS, ICD-10) aligned with documentation and payer
requirements?
- Are billing codes in compliance with the clinic's HRSA-approved scope of
services?
Timely Filing:
- Are claims submitted within the timely filing requirements for each payer?
- Is there a tracking system in place to monitor claims nearing timely filing
deadlines?
- Are denied claims resubmitted promptly within the payer's resubmission
window?
Denial Management:
- Are denied claims reviewed for root causes, including front-office errors,
coding issues, or incorrect insurance information?

4. - Is there a structured process for correcting and resubmitting denied claims
within a reasonable timeframe?
- Are front-office errors (e.g., demographic or insurance entry mistakes) a
frequent reason for denials, and if so, has staff been retrained to correct these
errors?
5. Payment Posting and Reconciliation
Objective: Ensure that payments received from payers and patients are
accurately posted and reconciled with expected payments based on fee
schedules and contract rates.
Payment Posting:
- Are payments from payers posted accurately against the contracted fee
schedule rates?
- Are payment discrepancies identified and corrected promptly (e.g.,
underpayments or overpayments)?
- Are adjustments, contractual allowances, and write-offs documented and
reconciled correctly?
Reconciliation with Fee Schedules:
- Are payments reconciled with payer-specific fee schedules to ensure the clinic
is being paid the contracted rate?
- Is there a system in place to track underpayments and ensure they are
appealed or corrected?
- Are patient payments, including copays, deductibles, and coinsurance,
accurately posted at the time of service?
Patient Balances and Payment Collection:
- Are outstanding balances followed up on promptly, including patient liabilities
not collected at the time of service?
- Is there a process for sending patient bills and following up on unpaid
balances?
- Payment Plan Options: Does the clinic offer payment plans to patients with
outstanding balances? Payment plans should allow flexibility for patients unable
to pay in full upfront, with scheduled payments spread over time.
- Are patients informed of their balances, and is there a structured collections
process in place to collect on overdue payments while ensuring compliance with
HRSA’s rule that patients cannot be denied service based on their inability to
pay?

5. 6. Financial Sustainability and HRSA Compliance
Objective: Ensure that the clinic’s billing practices align with HRSA compliance
requirements and that financial management supports the clinic’s sustainability.
Sliding Fee Compliance:
- Are sliding fee discounts applied accurately and in accordance with HRSA
guidelines?
- Are income verifications and discount applications updated at least annually?
- Does the clinic adhere to HRSA policies on nominal fees for patients below the
federal poverty line?
Patient Payment Plans:
- Are payment plans offered to patients who are unable to pay their balance
upfront?
- Are payment plan agreements tracked and managed to ensure regular
collections?
- Are patients informed that they are still eligible for services while enrolled in a
payment plan, in line with HRSA guidelines that prohibit denial of service based
on ability to pay?
Uniform Billing Practices:
- Are billing practices consistent for all patients, regardless of payer or ability to
pay?
- Does the clinic ensure no patient is refused service due to inability to pay, in
compliance with HRSA?
7. Staff Training and Process Improvements
Objective: Ensure that front-office and billing staff are adequately trained to
handle insurance verification, payment collection, and data entry, minimizing
errors and improving financial outcomes.
Front Office Training:
- Has the front office been trained on how to verify insurance eligibility and
accurately enter insurance data?
- Are front-office staff trained to calculate and collect copayments, coinsurance,
and deductibles at the time of service?
Ongoing Training:

6. - Is there a structured training program in place to keep billing and front-office
staff updated on payer policies, HRSA guidelines, and best practices?
- Are performance metrics in place to track the effectiveness of training (e.g.,
reduction in denials, increase in collections)?