Federally Qualified Health Centers and what do they do?
A Federally Qualified Health Center (FQHC) is a community-based organization that provides comprehensive primary care and preventive care, including health, oral, and mental health/substance abuse services to persons of all ages, regardless of their ability to pay or health insurance status. Thus, they are a critical component of the health care safety net. FQHCs are called Community/Migrant Health Centers (C/MHC), Community Health Centers (CHC), and 330 Funded Clinics. FQHCs are automatically designated as health professional shortage facilities. FQHC is a non-profitable, consumer-directed healthcare organization. FQHC serves the underserved, underinsured and uninsured people, and provides them with access to high quality and preventive medical health care. FQHCs were originally meant to provide comprehensive health services to the medically underserved to reduce the patient load on hospital emergency rooms.
FQHCs include community health centers, migrant health centers, health care for the homeless health centers, public housing primary care centers, and health center program “look-alikes.” They also include outpatient health programs or facilities operated by a tribe or tribal organization or by an urban Indian organization. FQHCs are paid based on the FQHC Prospective Payment System (PPS) for medically-necessary primary health services and qualified preventive health services furnished by an FQHC practitioner. Their mission has changed since their founding. Their mission now is to enhance primary care services in underserved urban and rural communities.
FQHCs and CHCs provide critical primary care services to tens of millions of people each year in this country. Their role in the front-line of healthcare makes them important entry points for patients entering the broader healthcare system. Let us see how these organizations use patient referral management systems to leverage their role as an important source of patient referrals and improve the care they can provide for their populations.
Improved care coordination
On average, one out of five patient appointments at an FQHC or CHC results in a referral. By definition, when a patient receives a referral it means there has been a change in diagnosis and it requires the advice of a specialist. A well-implemented referral management system helps ensure patients get the best possible access to care. It also makes the patient journey from primary care to the specialist as seamless as possible, even when providers are employed by different organizations or independent. Communication and sharing of data between different EMRs are highly impossible. This is where EMRs/EHRs tend to miss the mark.
Better referral workflows
Many primary care settings lack a centralized or coordinated method for managing referrals. It is common to learn that existing referral management involves the use of spreadsheets and is entirely manual. Referrals are send based on individual provider’s preferences. It is because referring providers don’t know who is in the network, nearby, available, and takes the patient’s insurance plan – but they do know who practices good medicine. This can lead to inconsistent patient experiences, more expensive healthcare overall, and deprives the clinic of taking full advantage of the referral volume they are sending into the medical community. With referral management software in place, it is easy to identify providers within the network who perfectly match the referral requirements.
Chronic care management revenue optimization
Many FQHCs and CHCs participate in programs such as Chronic Care Management (CPT Code G0511 or 99490) or 340B. Through the clinic’s ability to track and coordinate referrals, it leads to increased revenue for the clinic, which helps them continue to care for uninsured and underinsured patient populations.
Increased patient advocacy and access to care
Patients being referred from FQHCs and CHCs often have limited health insurance or no insurance coverage at all. It is a tremendous challenge for referral coordinators to find specialists who accept patients’ insurance plans (if they have insurance) and are willing to accept uninsured patients or underinsured because providers report they have much higher no-show rates, which means a loss of income for the specialist. Simply telling a patient they need to see a specialist and perhaps giving them a name and phone number isn’t enough to make a referral visit happen; it’s just the first step.
A referral management solution allows the clinic to curate and maintains a set of specialist resources that referring providers know both accept patient insurance plans and provide excellent care. This is a very essential step as it improves patient experience of the referral and increases their access to quality care.
Creating a more integrated provider network
Today, many organizations recognize their referral stream is a valuable point of leverage when advocating for patient populations. FQHCs and CHCs want better customer service, quicker appointment times and better care coordination with specialists. It is high time they recognize a referral management system which will allow them to organize, quantify, and eventually shape their referral stream. Many primary care organizations have found that pleas for better coordination with specialists go unheard until a change in referral patterns was included. When a referral management system is implemented, the network is more integrated and easy to handle.
Minimized out-of-pocket expenses for patients
For the longest time, organizations managed outbound referrals based largely on each referring PCP’s preference for individual specialists. This worked better in the open, PPO networks that were more common in the past. Now, however, narrow networks and varied plan participation by specialists can lead to high out-of-pocket costs and irate patients if they are referred to the wrong specialist. Referral management software solves this problem.