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Insurers UnitedHealth Group (UHC) and Aetna are engaged in a battle for customers in the retail pharmacy space, and urgent cares are caught up in the middle of the carriers’ rivalry. Are there potential urgent care billing implications?


Earlier this year, UHC-owned MedExpress partnered with Walgreens to pilot-test urgent care centers connected to Walgreens stores in several cities across the U.S. The facilities allow consumers to get medical treatment, purchase their prescriptions, and shop for items without having to make multiple trips. Early results of the pilots have been fairly successful for both UHC and Walgreens. In a move to compete with that success, just last week CVS announced its intent to purchase Aetna and transform CVS stores into “direct primary care facilities.” Those facilities will use CVS’ pharmacists and nurse practitioners to provide ongoing care for consumers with chronic conditions, such as diabetes, high blood pressure or asthma. Where the CVS/Aetna deal differs, however, is that CVS has a pharmacy benefits manager called CVS Caremark that it could potentially integrate with Aetna if the deal goes through.

The Implications for Urgent Care Contracts

With two major insurance carriers blurring the lines of health care delivery, where does that leave standalone urgent care centers?

Monica Klosa, chief operating officer of PV Billing, says she suspects the CVS/Aetna deal will produce many of the same urgent care billing obstacles that resulted when UHC first purchased MedExpress. “The CVS/Aetna deal is a very similar situation to UHC and MedExpress,” says Klosa. “When UHC bought MedExpress, it was tough to get new contracts because UHC had their own clinics. Aetna might not give new contracts to urgent cares that are near these CVS clinics, and they might use this deal to drive down reimbursement.”

According to Keri Alexander, president of contracting and credentialing at Practice Velocity, that means finding your negotiating power. “Because urgent care centers might not be able to get contracts, it might be important now for urgent care centers that are already participating with Aetna to try to renegotiate their contracts or try to lock in for longer terms on their contracts because, down the road, Aetna may not extend those contracts because they’ll have their own retail clinics.”

If you don’t already have contracts with Aetna in markets with CVS locations, Alexander says there are a few factors that might help you negotiate:

  • Evaluate the current market and determine what your unique value proposition is.
  • Research state legislation for “Any Willing Provider” statutes.
  • Compare the level of service your urgent care provides with the level of service provided at the CVS clinics to determine if there is a network need for your center.
  • If you aren’t already dispensing medications in house, it may be worthwhile to review your state legislation and consider adding this service so you remain competitive.

Alan Ayers, vice president of strategic initiatives at Practice Velocity, recommends that urgent care providers should encourage patients and local businesses to let their insurance carriers know how much they value their participation in the Aetna network.

“Within large insurance companies there are different departments with different motivations,” says Ayers. “While an actuary or finance function may demonstrate medical cost-savings by directing patients to a narrow network of fully owned or risk-based providers, such as physicians who receive incentive payments for keeping medical utilization down, there are completely separate network development and sales functions who are selling ‘access.’ Employers and employees want choice, so if a plan is too restrictive (i.e. patients can only use their benefits at an CVS in-store clinic), the insurance company may have difficulty selling the plan. Within an insurance company there is constant friction among the business, actuarial, and sales functions that has led many payors to offer open provider networks parallel to their captive providers. There’s no greater motivation to an insurance company to bring a provider in-network than the potential of lost employer groups.”

Even when an urgent care can obtain a contract with an insurance company, says Ayers, the other risk occurs when payors use plan design, such as co-pay differentials, to steer patients to the lower cost options. The patient may face a $0 to $20 co-pay with the preferred provider versus $80 or more at your center, plus the potential for the need for pre-authorization or referral from their primary care provider to use urgent care. Avoiding the hassle and saving money will drive patients to one urgent care center over another. This potential for steerage should be the greatest concern of urgent care owners and operators as payors acquire competing providers.

If you’re unsure how to negotiate your urgent care contracts, make sure your work with an experienced urgent care billing company that can get you the best rates.

PV Billing works the system harder to ensure your urgent care gets higher reimbursement, better collections and more revenue.

This resource was first published prior to the 2019 merger between DocuTAP and Practice Velocity. The content reflects our legacy brands.

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