Medical Billing Terms F: Fee Schedule, False Claims Act and FQHC

A fee schedule is the list of amounts a payer will pay for each billing code. This page defines it with the terms from face-to-face time to fully insured plan, including fee-for-service, the False Claims Act, FQHC and front-end edits. Each entry gives a plain definition, why it matters, an example, and an official source. MCM South Medical Billing Service, LLC works only in mental and behavioral health billing.

Last reviewed: October 10, 2026Sources linked at each term

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Billing Terms Glossary slide, Terms F: Fee Schedule - MCM South Medical Billing Service, LLC

Glossary pages

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On this page (19 terms)

Face-to-Face Time
Facility Rate
False Claims Act
Family Psychotherapy (90846 / 90847)
Federal Medical Assistance Percentage (FMAP)
Federal Poverty Level (FPL)
Federally Qualified Health Center (FQHC)
Fee Schedule
Fee-for-Service (FFS)
FHIR
Financial Hardship Policy
FinThrive
First Pass Resolution Rate (FPRR)
Florida Blue
Florida Statewide Medicaid Managed Care (SMMC)
Frequency Limit
Front-End Edit
FSA (Flexible Spending Account)
Fully Insured Plan

How to use these Fee Schedule definitions

Use this page as a quick reference for Fee Schedule, from Face-to-Face Time to Fully Insured Plan. Each entry gives a plain definition, why it matters to a mental health practice, and an official source. When a rule changes by payer or state, the entry says so, so confirm Fee Schedule details with the payer before you bill.

Checklist: put the fee schedule definitions to work

Face-to-Face Time: The time on a psychotherapy claim is face-to-face time, not the total time on the chart. Time spent on notes or calls without the patient does not count toward psychotherapy time.
Facility Rate: Choosing the wrong POS can change payment.
False Claims Act: Keeping known overpayments or billing without support can create exposure.
Family Psychotherapy (90846 / 90847): Payers differ on coverage and on which family member's plan is billed.

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Face-to-Face Time

General (all payers)

Also called face to face time; direct patient time

Definition: Face-to-face time is the time the clinician spends in direct contact with the patient, in person or by video, for a service coded by time. For psychotherapy codes, the patient must be present for all or some of the service.
Why it matters: The time on a psychotherapy claim is face-to-face time, not the total time on the chart. Time spent on notes or calls without the patient does not count toward psychotherapy time.
Illustrative example: A therapist's 50-minute session includes 45 minutes with the client, and the note shows the start and end time.

Reference sourceCMS Coverage Database, Article A57520 (First Coast)American Medical Association (AMA)checked 10/9/26

CategoriesClaims Processing Behavioral Health Specific Terms

Facility Rate

General (all payers)

Also called facility payment rate; facility setting

Definition: The Medicare payment level used when the service is delivered in a facility setting, typically lower than the non-facility rate.
Why it matters: Choosing the wrong POS can change payment.
Illustrative example: A service in a hospital setting is paid at the facility rate.

Reference sourceCMS (Centers for Medicare & Medicaid Services)CMS Physician Fee Schedulechecked 10/9/26

CategoriesPayment & Reimbursement Claims Processing

False Claims Act

General (all payers)

Also called FCA; qui tam

Definition: A federal law that imposes liability on those who knowingly submit false claims to the government, including in Medicare and Medicaid, and allows whistleblower suits.
Why it matters: Keeping known overpayments or billing without support can create exposure.
Illustrative example: A practice knowingly bills for services not rendered and faces FCA liability.

Reference sourceHHS Office of Inspector General (OIG)checked 10/9/26

CategoriesAudits & Compliance

Family Psychotherapy (90846 / 90847)

General (all payers)

Also called 90846; 90847; family therapy codes

Definition: CPT codes for family psychotherapy: 90846 without the patient present and 90847 with the patient present.
Why it matters: Payers differ on coverage and on which family member's plan is billed.
Illustrative example: A family session with the patient present is billed as 90847.

Reference sourceAmerican Medical Association (AMA)checked 10/9/26

CategoriesClaims Processing Behavioral Health Specific Terms

Federal Medical Assistance Percentage (FMAP)

Medicaid (state-specific)

Also called FMAP; federal Medicaid match; federal share of Medicaid

Definition: The federal medical assistance percentage is the share of a state's Medicaid spending that the federal government pays. It differs by state and is updated each year.
Why it matters: It explains why federal changes can affect state Medicaid budgets and rates. Providers seldom bill it, but it drives policy.
Illustrative example: A state announces a rate change and points to changes in the federal match.

Reference sourceMedicaid.gov CMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesMedicare & Medicaid Terms

Federal Poverty Level (FPL)

General (all payers)

Also called FPL; HHS poverty guidelines; federal poverty guidelines

Definition: The federal poverty level is an income measure that HHS issues each year and that programs use to decide eligibility. Medicaid, CHIP, and some assistance programs use percentages of it.
Why it matters: Practices use it to set sliding scale fees and to understand a patient's likely eligibility. Amounts change each year and differ by household size.
Illustrative example: A practice ties its sliding scale tiers to percentages of the poverty guidelines.

Reference sourceHHS (U.S. Department of Health and Human Services)checked 10/9/26

CategoriesEligibility & Benefits Patient Financial Responsibility Terms

Federally Qualified Health Center (FQHC)

Medicare and Medicaid

Also called FQHC; community health center billing

Definition: A federally qualified health center is a community-based health care provider that meets federal requirements and receives certain federal support. Medicare and Medicaid pay FQHCs under special payment methods rather than the standard fee schedule.
Why it matters: Behavioral health services at an FQHC follow FQHC billing rules, which differ from an independent practice's rules. Confirm the coding and payment rules before you bill.
Illustrative example: A therapist employed by an FQHC bills under the clinic's rules, not the standard professional claim rules.

Reference sourceCMS (Centers for Medicare & Medicaid Services)HRSAchecked 10/9/26

CategoriesMedicare & Medicaid Terms Behavioral Health Specific Terms

Fee Schedule

General (all payers)

Also called payer fee schedule; rate schedule; reimbursement schedule

Definition: A list of amounts a payer will pay for specific service codes, often tied to a benchmark such as the Medicare fee schedule or set by contract.
Why it matters: Provides the basis for expected payment and audit of remittances.
Illustrative example: A practice loads its payer's fee schedule into billing software to flag underpayments.

Reference sourceCMS (Centers for Medicare & Medicaid Services)CMS Physician Fee Schedulechecked 10/9/26

CategoriesContracting & Network Management Payment & Reimbursement

Fee-for-Service (FFS)

General (all payers)

Also called FFS; traditional payment

Definition: A payment model in which providers are paid for each service delivered.
Why it matters: The default model for most outpatient behavioral health.
Illustrative example: A therapist is paid per session.

Related termsValue-Based Care Capitation

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesValue-Based Care Terminology Payment & Reimbursement

FHIR

General (all payers)

Also called Fast Healthcare Interoperability Resources

Definition: An HL7 standard for exchanging health data using modern web technologies and APIs.
Why it matters: CMS and payers are moving toward FHIR-based APIs.
Illustrative example: A payer exposes claims data through a FHIR API.

Reference sourceHL7 FHIRchecked 10/9/26

CategoriesEHR & Healthcare Technology Terms EDI & Clearinghouse Terms

Financial Hardship Policy

General (all payers)

Also called hardship policy; financial assistance policy

Definition: A written policy that lets a practice reduce or forgive patient balances based on documented financial need, applied consistently.
Why it matters: A documented policy is the safer way to reduce balances than ad hoc waivers.
Illustrative example: A practice reduces a balance under a written income-based policy.

Reference sourceHFMAchecked 10/9/26

CategoriesPatient Financial Responsibility Terms Audits & Compliance

FinThrive

General (all payers)

Also called FinThrive revenue cycle

Definition: A revenue cycle technology and services vendor for health care providers. Listed for reference; not an endorsement or partnership.
Why it matters: Appears among revenue cycle vendors, mainly for larger organizations.
Illustrative example: A health system uses FinThrive for revenue integrity.

Reference sourceFinThrivechecked 10/9/26

CategoriesRevenue Cycle Metrics

First Pass Resolution Rate (FPRR)

General (all payers)

Also called FPRR; first pass rate; first-pass acceptance rate

Definition: The percentage of claims paid on first submission without rework, denial, or appeal.
Why it matters: Higher FPRR means less rework and faster cash.
Illustrative example: A practice tracks FPRR by payer each month.

Reference sourceHFMAchecked 10/9/26

CategoriesRevenue Cycle Metrics Claims Processing

Florida Blue

Private payer

Also called Blue Cross and Blue Shield of Florida

Definition: Florida's independent Blue licensee. It is not part of Anthem.
Why it matters: Florida Blue rules apply to Florida Blue members only.
Illustrative example: A Florida provider uses the Florida Blue provider site.

Reference sourceFlorida Bluechecked 10/9/26

CategoriesBCBS, UHC & Commercial Payer Terms

Florida Statewide Medicaid Managed Care (SMMC)

Medicaid (state-specific)

Also called SMMC; Florida Medicaid managed care

Definition: Florida's Medicaid managed care program delivered through contracted plans.
Why it matters: Florida is a served state; plans set their own rules.
Illustrative example: A Florida provider contracts with SMMC plans.

Reference sourceMedicaid.govchecked 10/9/26

CategoriesMedicare & Medicaid Terms BCBS, UHC & Commercial Payer Terms

Frequency Limit

General (all payers)

Also called frequency limitation; visit frequency rule

Definition: A payer or program rule that limits how often a service can be billed, such as how many times a diagnostic evaluation can be billed in a period.
Why it matters: Billing beyond the limit leads to denials.
Illustrative example: A payer allows one diagnostic evaluation per patient per period unless there is a change in condition.

Reference sourceCMS (Centers for Medicare & Medicaid Services)checked 10/9/26

CategoriesClaims Processing Behavioral Health Specific Terms

Front-End Edit

General (all payers)

Also called clearinghouse edit; pre-submission edit

Definition: A check applied before the claim reaches the payer to catch errors.
Why it matters: Reduces payer rejections.
Illustrative example: A front-end edit flags an invalid modifier.

Reference sourceX12checked 10/9/26

CategoriesEDI & Clearinghouse Terms Claims Processing

FSA (Flexible Spending Account)

General (all payers)

Also called FSA; flexible spending account

Definition: An employer-sponsored account that lets employees set aside pre-tax dollars for qualified medical expenses.
Why it matters: Some patients pay copays with FSA cards and may need itemized receipts.
Illustrative example: A patient submits a superbill for FSA reimbursement.

Reference sourceHHS (U.S. Department of Health and Human Services)checked 10/9/26

CategoriesPatient Financial Responsibility Terms

Fully Insured Plan

General (all payers)

Also called insured plan

Definition: A plan in which the employer pays premiums to an insurer, which carries the risk and is subject to state insurance regulation.
Why it matters: State laws, including some behavioral health mandates, typically apply.
Illustrative example: A small employer buys coverage from a Blue plan.

Related termsSelf-Funded Plan State Mandate ERISA

Reference sourceU.S. Department of Labor, EBSAchecked 10/9/26

CategoriesEligibility & Benefits BCBS, UHC & Commercial Payer Terms

Quick answer: Fee Schedule

What is a fee schedule?

Fee Schedule is a list of amounts a payer will pay for specific service codes, often tied to a benchmark such as the Medicare fee schedule or set by contract. Provides the basis for expected payment and audit of remittances.

Frequently asked questions: Fee Schedule

What is fee-for-service?

Fee-for-Service (FFS) is a payment model in which providers are paid for each service delivered. The default model for most outpatient behavioral health.

What is the False Claims Act?

False Claims Act is a federal law that imposes liability on those who knowingly submit false claims to the government, including in Medicare and Medicaid, and allows whistleblower suits. Keeping known overpayments or billing without support can create exposure.

What is a front-end edit?

Front-End Edit is a check applied before the claim reaches the payer to catch errors. Reduces payer rejections.

Related resources

Where MCM South works

MCM South serves psychotherapists and psychiatrists in ten states: Georgia, Massachusetts, Connecticut, Texas, Florida, New York, Colorado, Tennessee, North Carolina and Illinois.

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