Reimbursement for Christmas and New Year’s Hours

The holiday season, for many people, is a time of festive cheer—decorating your home, attending get-togethers with friends and co-workers, spending quiet time with loved ones, exchanging gifts and cards, helping those in need, and indulging in food and drink.  But these activities can also spread viruses and bacteria, spur seasonal indoor allergies, bring indigestion or food poisoning, or even lead to physical injuries due to decorating, icy weather, and travelling.  Depending on the when the flu season hits, December can be one of the busiest months for urgent care centers. The busiest day tends to be the day after Christmas, December 26th.

According to an analysis of centers utilizing Practice Velocity’s EMR and practice management software, approximately 21% of urgent care centers are open on Christmas Day and nearly 50% are open on New Years’ Day.

Ideally, a “best-in-class” urgent care center will be open for business 10-12 hours per day, 7 days a week, 365 days per year…reinforcing the “care when you need us” philosophy that sets urgent care apart from other medical providers. However, the difficulties of provider holiday scheduling, the desire for staff to enjoy time off with their families, and the need to maintain profitable operations discourage many centers from being open on major holidays like Easter, Thanksgiving, Christmas and New Years.  Paying team members time-and-a-half, overtime, and even double time in the absence of higher-than-normal patient volumes means centers often lose money on holidays.  But a center that doesn’t realize a profit can still reap long-term benefits if holiday hours are part of an overall marketing strategy emphasizing convenience and accessibility of the center.

And some fee-for-service payers do provide additional reimbursement for visits on major holidays.  CPT code 99051 is an add-on for services provided at the urgent care center during regularly scheduled evening, weekend or holiday hours, in addition to basic services. According to PV Billing, 99501 can yield $25-50 in reimbursement above and beyond the E/M level of service billed.

Now, not all payers will reimburse these “extended hours” codes—especially if the urgent care center is contracted at a flat reimbursement per encounter as opposed to fee-for-service. Medicare and Medicaid also do not reimburse this code. But many payers do recognize the value of extended hours and will indeed compensate, even if only occasionally.  Urgent care centers billing place of service code 20 have reported success with some regional payers accepting the 99051 code on federal holidays while physician’s offices billing place of service 11 have reported greater success using after-hours codes on fee-for-service contracts.

A starting place should be to evaluate payer expectations.  Does the payer expect, by contracting as an urgent care, that the center will be open certain holidays?  When facing payer denials of the 99051 code, the trick seems to be presenting a compelling case that by offering holiday hours, the urgent care effectively diverts patients who would otherwise visit the more expensive Emergency Room for treatment—which of course means higher costs for the insurance company.

Even if the payer rejects reimbursement of the 99051 code, having an archive of claimed charges can help make the case during the next contract re-negotiation for increased reimbursement based on the center’s availability and activity on those days.

Alan A. Ayers, MBA, MAcc