5 Silent Revenue Killers in Your FQHC Billing Process

Key Takeaways

• Denials are only half the story. Most FQHC billing teams don’t have visibility into why claims are getting denied, making it hard to fix root causes.

• Without routing denial insights back to front-end staff or providers, teams keep firefighting the same issues.

• With providers doing their own coding and no validation layer in place, key details are often missed, leading to preventable denials.

• Teams are too stretched to chase aging claims or monitor wrap-around payments, leaving critical revenue behind.

• Autonomous Coders & Billers like CombineHealth’s Adam, Amy, and Jessica can automate denial analysis, documentation review, and A/R follow-up.

In our recent calls with health centre leaders, we’ve been spotting some recurring patterns:

• A biller spending 80% of their time juggling tasks manually, which has a higher chance of human errors
• A front-office team juggling Medicaid eligibility with no visibility into why wrap-around payments never arrived
• A provider is unsure how to code a visit because the EHR guidance didn’t match what payers actually want

These aren’t isolated headaches, but they’re signs of deeper cracks in the revenue cycle foundation. 

In this article, we’ll spotlight five silent revenue killers we uncovered through real conversations with customers and prospects and explain how AI-powered solutions can help in the FQHC billing process.

1. Lack of Visibility Into What’s Causing Denials

In nearly every conversation we’ve had with FQHC billing teams, one theme keeps coming up:

“We’re seeing denials coming in, but we don't always know the root cause. Is it documentation? Coding? Something with eligibility? It’s hard to tell.”

It’s a structural flaw we see in most FQHC RCM setups. 

Even when they can see the denial code, it doesn't always clarify the true issue or what action to take next. This lack of clarity creates extra work for the team—forcing them to manually trace the denial back to what happened during billing or patient intake.

How To Fix It?

One effective approach is to connect each denial to a specific failure point in the workflow, rather than just tracking denial categories like “CO-50” or “CO-197.” 

This can be done by setting up automation workflows that:

• Categorize denials not just by code, but by actionable root cause (e.g., “modifier missing,” “documentation insufficient for level 4,” etc.)
• Continuous learn from prior denial patterns to flag recurring gaps tied to specific services, providers, or payer types

2. No Feedback Loop Across RCM Workflows

Most finance leaders at community health centers admit that a typical RCM team (coders, billers, and denial managers) works in silos. Denials are reviewed and resolved, but insights from those denials rarely make it back to the root teams who could’ve prevented them in the first place.

Without a feedback loop, RCM teams remain reactive instead of proactive. 

Example:

Here’s what the CFO of a community health center recently revealed to the CombineHealth team: 

They consistently faced level-of-care downgrades in ER cases. But the coding team wasn't aware until the denial hit weeks later.

This lag leads to recurring mistakes, revenue leakage, and burnout—especially when the same claim types are fixed over and over again, without anyone knowing the “why” behind the issue.

How To Fix It?

Building an internal feedback loop, which could involve:

• Tagging claims with recurring issues and notifying the relevant team of the root cause and examples
• Using denial data to generate insights for training (e.g., flagging frequent documentation errors in certain encounter types).
• Automating the delivery of these insights across workflows, such as sending coding improvement suggestions directly within EHR task queues or coder dashboards

3. No Way To Validate Whether the Documentation and Coding Meet the Standard

Providers often write notes and assign codes themselves. But there’s no reliable way to check if the documentation supports the codes or meets payer rules.

“A lot of our denials were tracing back to documentation gaps or coding misses.”

- CombineHealth's Customer

Without any real-time validation of clinical documentation, denials circulate downstream as recurring issues:

• Claims for higher-level E/M codes get downgraded due to insufficient documentation.
• Modifiers or coverage rules often get denied if the notes don’t explain them clearly.
• Teams end up chasing documentation post-denial, resulting in a time-consuming administrative cleanup.

How To Fix it?

One way RCM teams could address this is by integrating real-time documentation integrity checks into the clinician workflow. 

Here’s how CombineHealth’s Jessica (our AI scribing agent) handles it:

1. Transcribes provider–patient conversations in real-time
2. Organizes them into structured encounter notes
3. Flags documentation issues that you can accept or reject
4. Updates clinical notes with the suggested changes

Recommended reading: How AI can help close clinical documentation gaps

4. Providers Are DIYing the Coding and Billing Process

 In many FQHCs, providers wear too many hats. They’re not just delivering care, but are also coding the visit, entering billing details, and reviewing documentation. 

While this might seem efficient on the surface, it often comes at the cost of accuracy, speed, and burnout.

Here’s what a revenue cycle leader at a community health center shared with us:

“Sometimes the provider didn’t select the right code, or left something off... and we only find out once it’s denied.”

When you don’t separate clinical and coding responsibilities, two things happen:

1. Providers get overwhelmed trying to remember coding rules and payer-specific nuances while seeing patients.
2. Errors and omissions creep into the documentation, and that triggers denials down the line.

How To Fix It

Start by separating the clinical and coding workflows. Instead of putting the burden on providers, give them tools that can assist them. Just by having an AI-powered coder and biller in your team, you can get so much done with maximum efficiency and accuracy, without burning your providers out.

5. No Bandwidth for A/R Follow-up

For some FQHCs, wrap-around payments can represent up to 23% of Medicaid revenue^[1]. That’s revenue you can’t afford to leave on the table. And A/R follow-up is often the first thing that slips when teams are stretched thin. 

These payments are critical for keeping community clinics running. But without constant follow-up and documentation alignment, they’re easy to lose.

Here’s what we often hear from health center leaders:

“Once the claim goes out, we don’t have people watching to make sure everything gets paid. And if it didn’t, it just sits there.”

And the consequences stack up fast. Aging A/R balloons, write-offs increase, and staff get stuck in reactive mode chasing denials rather than strategically recovering revenue.

That’s when an AI A/R specialist (like CombineHealth’s Adam) takes the burden off you. Here’s how the process typically goes:

1. Checking claims through payer portals, chatbots, and even Availity
2. Making calls to payers with their IVRs and live agents to resolve denials, leave voicemails, and handle inbound calls
3. Prioritizing claims based on age, value, or payer rules

Improve Patient Care by Fixing Billing Gaps

The truth is: Most FQHCs aren’t losing revenue because of one big mistake. They’re losing it in the margins. 

Missed denial patterns. 

Documentation that never makes it back to billing. 

Eligibility checks that fall through the cracks. 

These silent killers add up over time, quietly eating into margins and overwhelming already-stretched teams. And when that happens, your patient care gets impacted. 

But it doesn’t have to stay that way!

With AI agents like Adam, Amy, and Jessica working behind the scenes, you can finally break free from the cycle of rework and revenue loss. 

Remember, it’s not about replacing your team. It’s about giving them the tools (and time) to focus on what matters most: providing care to as many patients as possible, while getting paid on time, always!

Book a demo with us to learn more about our AI platform.

FAQs

What is FQHC billing, and why is it important?

FQHC billing refers to how Federally Qualified Health Centers are reimbursed for patient services under Medicaid and Medicare. It’s crucial because FQHCs rely on accurate, timely payments to sustain care for underserved populations

What is a wrap-around payment for FQHC?

It’s an additional payment from Medicaid to FQHCs to “wrap around” what they’re paid by managed care plans, ensuring the clinic receives their full PPS (Prospective Payment System) rate for covered services.

References

^[1]Geigergibson. https://geigergibson.publichealth.gwu.edu/sites/g/files/zaxdzs4421/files/2022-09/talevski-impact-data-note-september-2022.pdf, sourced August 4, 2025