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False claims cost $27K+ each. One billing error can cascade into payback demands.
Key PPS same-day rules: • Medicare: 2 encounters allowed on the same day if the patient sees two different providers for two different services (e.g., medical + behavioral health). Each encounter must have a qualifying face-to-face visit with a billable provider. • Medi-Cal: Generally 1 PPS encounter per day. Medical + BH typically counts as 1 visit. Exception: some managed care plans allow 2. • FQHC APM (Alternative Payment Model): Capitation changes the equation entirely — per-member-per-month, not per-visit. • Critical: FQHCs CANNOT bill 'incident-to' like private practices. Every encounter must be directly billed under the rendering provider's credentials. • Documentation: Face-to-face requirement means the billing provider must personally see the patient. Co-signing a note does NOT equal a face-to-face encounter.
FQHC billing Medicare 'incident-to' a physician — NOT allowed for FQHCs. Can trigger False Claims Act liability.
Submitting claims for encounters where provider did not have qualifying face-to-face contact with patient.
Receiving both 340B drug discount and Medicaid rebate on same prescription — prohibited under 340B statute.
Consistently billing higher E/M levels than documentation supports. Triggers payer audits and FCA risk.
AI medical documentation scribes (e.g., Abridge, Suki) may introduce billing compliance issues: hallucinations in diagnosis codes, upcoding through AI interpretation, medication errors not caught by clinician. OCR has not yet issued guidance on AI-scribe liability.
HRSA 340B audits increasing post-Saldanha v. HHS court ruling. HRSA enforcing stricter contract pharmacy reconciliation, patient eligibility verification, and split-billing compliance. Non-compliance findings leading to repayment orders and program probation.
FQHCs receive a per-visit PPS rate from Medicaid (and cost-based from Medicare). Rate covers all services in a single encounter. Must understand same-day billing rules.
CMSImposes civil penalties for knowingly submitting false claims to the government. Penalties: $13,946 to $27,894 per false claim plus treble damages. Whistleblower (qui tam) provisions.
U.S. Department of JusticeRequires drug manufacturers to offer outpatient drugs at significantly reduced prices to eligible entities including FQHCs. Savings of 25-50% on drug costs.
HRSA Office of Pharmacy AffairsProhibits offering, paying, soliciting, or receiving anything of value to induce referrals for services covered by federal healthcare programs. Criminal penalties.
HHS Office of Inspector GeneralProhibits physicians from referring Medicare/Medicaid patients to entities with which the physician has a financial relationship, unless an exception applies. Strict liability — no intent required.
CMSPhases in $25/hour healthcare minimum wage for FQHCs by June 1, 2027. Current FQHC rate: $21/hour (effective June 2025). Applies to all healthcare workers in qualifying facilities.
California Legislature