Medical Billing Best Practices for Optimal Revenue in Urgent Care
March 18, 2024
Not recouping revenue owed is the number one most solvable revenue issue most urgent cares have. This includes rejected or denied claims, and also failure to follow-up on money owed. And you’re not just leaving money on the table — inaccurate claims cost you more.
According to Ben Tischler, Experity Senior Vice President of Revenue Cycle Management Sales and Solutions, “If something gets rejected or denied, it costs you five times the effort to get it paid than if it went through cleanly.” Josh Rainey, Experity Vice President of Client Success, noted that outside of labor costs, per MGMA, the cost of reworking the average claim is $25 because of the inherent bad debt risk with lack of a first pass clean claim.
There’s a lot you can do to protect your revenue by following some medical billing best practices across front desk processes, payer and coding practices, reporting, and other opportunities in-clinic.
Front desk staff have the lowest paid positions in the clinic, the highest turnover, and yet the most important role in the revenue cycle. This first stage is where the most mistakes are made — collecting critical, accurate information from patients. And if something is missed here, everything will be wrong when it’s time to bill.
In fact, registration and eligibility errors are the single biggest reasons for exceptions. So let’s tackle how to manage that.
A sophisticated patient engagement (PE) tool is critical to a profitable clinic, especially as patients rely more heavily on technology. Whether you allow patients to reserve a spot in line, walk in, or digitally check in, prompt them to register themselves online. They can upload insurance images and fill out most of their own information. When your PE is integrated with your PM, pre-registration greatly improves accuracy that prevents denials and speeds up the entire pre-visit process for your staff.
A PM well-suited for urgent care has real Time Eligibility (RTE) or Real Time Verification (RTV) built in so you can verify insurance before the visit. Best practices here are to verify patient insurance every applicable time for every visit — and to take the proper action based on the result. For example, ensure that Medicaid patients re not actually covered by a Medicaid CMO, or create a payment plan with the patient when you find they are not covered by insurance.
If your PM doesn’t have this option, make sure staff calls or checks the insurance payer’s portal during (or if possible, before) the patient visit to make sure insurance is valid.
One of the quickest ways to resolve outstanding payments is to adopt a credit card on file program — or use a PM with this capability. With the patient’s permission, you can charge their credit card with the amount that’s left over after the claim goes through. And it’s more convenient for the patient because it’s a step they don’t have to think about again.
Not everyone feels comfortable asking for money. Find the people who do, and then arm them with a script to make this request easier. For example:
“I see you have a $25 dollar copay. Want to give me your credit card and I’ll take care of it? Oh! I see you owe $10 from your last visit. Is it OK if I just go ahead and put that on here, too?”
Collecting money from patients is much easier while they are physically in the clinic, so collect money up front instead of risking patient responsibility going to collections.
This may or may not be part of your front desk processes if you have separate billers. After receiving claim payment, accurate payment posting is essential to reducing bad debt. While it’s ideal to submit clean claims the first time, clinics often make the mistake of automatically writing off unpaid charges that can be appealed or corrected — and then resubmitted. If charges can be received from a payer with a few corrections, it’s worthwhile to take this additional step to ensure accurate revenue intake.
For unpaid balances that are not collected in-clinic, it’s important to have a process to collect post-visit. The quickest, simplest, most cost-efficient way to do this is via text balance reminders through your PM. These texts contain a direct link to either pay their bill or call the clinic’s billing number. A paper statement won’t be sent until three texts have failed to collect payment — which also saves your clinic the cost of paper bills. If you don’t have this capability, make it routine for your staff to follow up with a call after a set number of days in A?R.
Of course, there are a minutia of other steps within the check-in and check-out process that can help you recoup more revenue. This blog has a link to a front desk checklist PDF you can use, and it covers some other tips to improve front desk operations.
Clinic providers, owners, and managers also contribute to rejections and denials — often resulting from missed steps or lack of awareness in industry updates like coding. These best practices help you avoid these mistakes for improved revenue.
If your clinic has poor or no payer contracts, this will be directly reflected in your clinic’s reimbursement. Only when this is corrected will claims be processed and paid correctly.
Make sure you’re contracted with the payers in your area — preferably prior to opening your urgent care. If you wait to negotiate contracts, your clinic will not be able to accept insurance from patients in your area. While you can accept only cash-pay patients, your patient visits may stay low until more contracts are in place.
Advice: Hire a professional contracting expert who knows payers in your region. They will negotiate on your behalf, understand the fine print details, and know the best contracted rates for your region. Having a versed professional on your side will help you negotiate better rates — especially if you are a new urgent care.
Providers tend to get comfortable with their E/M code selection. Choosing a “just-right” Level 2 or 3 code is seen as a more prudent coding choice than choosing higher level codes — even if documentation supports a higher code level. If providers consistently select lower code levels than services performed, your practice could be losing hundreds of dollars a day.
The American Medical Association updates CPT codes annually. If your coding team isn’t up on code changes and isn’t re-certifying for updates, your claims could be submitted with dated info, resulting in lost revenue.
An EMR built for urgent care can also help you code correctly as it’s programed to provide coding recommendations based on the most frequent episodic visits.
Often, services don’t fit nicely into one CPT code—so modifiers can make the difference with explaining what exactly was provided to the patient. For example, if a patient had two distinct procedures performed during the same encounter. Code modifiers can easily be missed, used incorrectly, or abused. It’s also important to understand each payer’s requirements. Individual payers have varying levels of acceptance of certain modifiers, and the misuse of modifiers will cause claim denials.
Understanding HCPC levels is key to accurate reimbursement. HCPC Level 1 codes refer to CPT code charges. HCPC Level II codes are included for injectable drugs, medical equipment, or supplies provided in addition to treatment — such as splints or crutches. If you supply medical equipment, ensure you use correct code modifiers to prevent denials.
It’s important to ensure provider credentialing is in order, along with the related system configuration, in order to get paid. This should be done quarterly to ensure nothing falls through the cracks.
Need help billing for non-credentialed and non-contracted providers? Read this blog >>
Auditing, reporting, and KPIs are important to your financial success and key to optimized medical billing practices. We’ve covered ten metrics that matter to urgent care success in several resources — if you haven’t seen them, you can download a simplified explanation of these and how to calculate them here. In addition, here are a few best practices you can follow for revenue cycle management (RCM) health.
These should include, but may not be limited to:
This helps you know not only how you are performing, but where you need on for improvement, and how well your efforts are working to make a difference.
The reporting that your PM provides can give you a broader look at your overall financial performance. You always want to know how well you’re doing or what is changing month-to-month so that you can accurately identify trends, changes, opportunities, and wins. Data will help you make better decisions not only around RCM, but also guide you in smarter business decisions like staffing, hours of operations, and budgeting. If it feels too complicated to get the data you need from your reporting tool, you may want to consider a business intelligence solution.
You want to look for trends in denials so you can properly train staff on correcting them, and you can update your standard operation procedure (SOP) to reflect protocols that help you avoid these mistakes. You may find that one staff member is better or worse in an area and use that opportunity for peer coaching.
See if you’re potentially under- or up-coding based on benchmark patterns. If using an EMR, see if providers regularly select a code other than what the system suggests or are selecting a single code level frequently. Make sure your coders are up to date on code changes.
There are a few other recommendations we can make to help you prevent revenue loss in the medical billing process.
Incomplete documentation causes missed charges. Common missed charges include labs, blood draws, administration of an injection, x-rays, and the reading of results.
In addition, providers can fail to document units of service (or drug dosage amounts). Quantity of dispensed drugs need to be noted accurately so the correct charge can be stated on the claim. Poor documentation for procedures will cause delayed claim submission or missed reimbursement.
Teach providers to document commonly missed charges like labs and injections. Have an easily reviewable list and common conversion table for drug dosage. Keep a log of all requested labs and drugs dispensed; double check these against claim charges.
All of these best practices translate to one or more SOPs that can help train and guide your staff to keep them consistent and also ensure they’re clear on what you need them to do. Remember to also train your current staff on any new processes or steps you may implement in an effort to improve.
We’ve mentioned a number of technology features throughout this article that can help make billing easier and more accurate. Outdated technology can hurt your business by making you less efficient, more prone to mistakes, and also less appealing to patients. Here is a snapshot of what we’ve discussed:
If interested, you can learn more about Experity’s solutions here >>
One question that may come up when looking to improve RCM is whether it makes more financial sense to take on these improvements with in-house billing or to outsource to a team of experts. This is a valid concern for urgent cares of all sizes. If you don’t have the time or expertise to stay on top of the many details that go into billing — including catching possible mistakes, following up on A/R, payer contracting, and resubmitting claims, it may easiest and most cost-effective to outsource. You can review the pros and cons of in-house versus outsourced billing in our eBook >>
Additionally, you can review Experity’s RCM services here >>
Cleaning up your medical billing process can feel overwhelming. You may not know which advice to start with or where you need the most help. Outsourcing your billing is a big decision. There is an option that sits in-between tackling everything alone and signing on with a third-party vendor. Experity offers a free billing analysis that shows you where you can start making the most impactful improvements to your RCM.
While most urgent care owners are confident they are getting claims out and posting cash efficiently, those tasks only account for 30-40% of the revenue cycle. What our RCM experts have found in over 400 billing audits is that clinics are making the same mistakes in the other 60-70% — and had no idea there was so much room for improvement. There is no obligation to sign on to our RCM services. If you need help, sign up today.
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