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Coding and Reimbursement Challenges in the Urgent Care Setting

Urgent Care differs from primary care and emergency care mainly in the nature of the urgency of any condition that needs to be treated. Conditions ranging from fever to minor accidents that are not considered an emergency but require treatment within 12 hours fall under urgent care.  Apart from this, urgent care costs also vary significantly from both primary and emergency care and fall somewhere between the two. Many patients choose to visit urgent care because of the short wait time. This tendency has inflated the volume of patients seeking urgent care and hence, has increased revenue from urgent care. By 2023, the market of urgent care has been estimated to reach $26 billion.

However, many practices find that in spite of having a large volume of patients visiting their urgent care, their revenue is stagnant. This is chiefly due to issues with reimbursements as a result of various challenges in medical coding, reimbursement rules, and regulations that private practices face while making reimbursement claims for urgent care.

How Is Urgent Care Billing Different?

As the conditions dealt with by urgent care are almost similar to the conditions that a primary care provider treats, there are not many differences in billing processes between the two. But, there are a few medical codes that are specific to urgent care only. These codes start with an ‘S’. Codes beginning with an ‘S’ are only used in urgent care settings.

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Except for Medicare, all urgent care can fall under two main code categories for billing.

S9083

S9083 is a code specific for urgent care that allows providers to charge a global fee, regardless of the medical service provided. This can be a non-sensible option that is best avoided as the charges will be universal for all treatments provided.

S9088

S9088 is another code for urgent care providers to charge bills for any medical services provided, such as patient evaluation and treatment. This code allows providers to charge services at relatively higher costs for urgent care.

Also Read: In-house Medical Billing Vs. Outsourced RCM

Challenges in Urgent Care Billing

Regulations In Coding

Although urgent care has many similar coding guidelines as primary care, it is up to the coder to decide which urgent care codes are most appropriate for a particular medical service while also making sure the codes satisfy regulatory guidelines. Furthermore, urgent care bills must also comply with certain rules of the insurance provider prior to claim submission. If they fail to do so, urgent care claims are likely to be denied.

Limited Time to Confirm Insurance

Due to the urgency of the situation, most urgent care providers do not have sufficient time to confirm the insurance coverage of the patient. Failure to pre-authorize for any medical service with the insurance company increases the likelihood of claim denials owing to lack of coverage.

Centers for Medicare and Medicaid Rules

Centers for Medicare and Medicaid (CMS) are responsible for setting rates of reimbursement by Medicare for medical services. In 2021, CMS announced the new Medicare physician fee schedule, which denotes lower reimbursement for all urgent care and emergency medical services.

Medicare Limitations

Although Medicare covers more than 80% of urgent care costs, this coverage does not include the higher costs of medical services in an urgent care setting. Medicare considers urgent care treatments to be in a similar range as primary care treatments and usually pays in a likewise similar range. Most urgent care accepts Medicare, but it may be less profitable than private insurance in the case of urgent care reimbursements.

Good Practices for Urgent Care Billing

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Confirm Financial Responsibility First

If you fail to confirm that a patient is medically insured prior to providing any urgent medical care, you may be faced with billing issues after the service has been provided. Start confirmation of financial responsibility early on. If the patient is unable to verify or recall their insurance details, you must have the patient sign an advance beneficiary notice, indicating that they bear the costs of the treatment.

Outsource Your Billing

Medically trained staff and physicians are often oblivious to the financial sides of a medical practice. While hiring your own personal in-house medical coder can be done, it is a costlier and error-prone option. Instead, you can outsource your billing to revenue management service providers such as Practolytics, who are experienced in dealing with medical insurance companies and have highly skilled experienced medical coders.  With clients spread across 26 States, Practolytics has an edge over other players in the market when it comes to urgent care billing.

Ensure Error-free Claims

CMS is more likely to deny claims for urgent care than primary care service, which will further complicate and delay reimbursement. By ensuring that all codes are appropriate as per the regulations set by the insurance provider, Medicare or commercial, you can minimize the rate of claim denials.

Conclusion

Insurance claims for urgent care can be trickier and more prone to denials. As costs of urgent care are usually higher, insurance providers tend to be more stringent with the rules for reimbursement with regards to urgent care.

Dealing with medical billing, claim denials, revenue cycles, and other financial aspects of a private medical practice can be complex and frustrating. We, at Practolytics, are here to unburden you from all the complicated processes of medical insurance and help you make a profitable income from your practice.

Also Read: Medical Billing Audit Checklist: 10 Things to Keep in Mind