Understanding and Managing Payer Contracts in Urgent Care

Effectively managing payer contracts is essential to ensure healthcare providers get fair payment for their services and can continue to provide high-quality care to patients. The latest issue of Urgent Care Quarterly covered this topic along with other revenue cycle trends. Here is an overview of what was shared regarding payer relationships.

Changes in Billing Codes

Some large national payers have stopped using the S9083 code for case-rate visits. Instead, they now require billing with Evaluation and Management (E/M) service levels and applicable procedure codes, even for clinics with case-rate contracts. The payer’s system will adjust the claim to the case rate when determining payment. While this might seem like extra work, it’s important to document and code claims at the E/M level. This ensures accurate records and helps maintain your case rate.

Challenges in Negotiating Contracts

Differing reimbursement schedules, different rates for similar services, and managing a numerous network participation requirements all make negotiating payer contracts quite complex. Successful negotiation relies a lot on you knowing and tracking your clinic trends and market data. Payers aim to reduce their costs, so you need to make a strong case for improving your contract by:

Providing proof of increased overhead costs, salary requirements, hours of operation, and any other costs that can justify your request
Showing how your services benefit the community, such as reducing emergency department visits and providing convenient care for underserved populations. It can help to get references from community groups or schools you have supported
Emphasize that your success in the community helps the quality of life and wellness for everyone

For example, if you want a fee-for-service contract, provide data showing that by treating more complex medical issues, you help keep patients out of the emergency room, saving the payer money and reducing ER staff shortages. Highlight how urgent care visits and regular follow-ups can prevent more critical care later.

If you are happy with a case-rate contract but want better rates, provide proof of rising costs in patient care. Accurate historical visit documentation based on E/M levels is critical to supporting your case for a higher rate.

Importance of Well-Negotiated Contracts

Fair and well-negotiated contracts enable providers to offer quality care while maintaining financial health. Make sure you understand the fine print of contracts and build a centralized system for managing them so you’re better prepared to renegotiate and improve your terms. Most contracts include a date after which you can renegotiate, so mark this date on your calendar to review as soon as you can.

Types of Contracts in Urgent Care

In the urgent care market, contract assignments can differ based on ownership, contract type, the year the contract was issued or renegotiated, market saturation, and other factors. Most urgent care clinics have either a global (case-rate) or fee-for-service contract.

Global Case-Rate Contracts: Suitable for clinics focusing on high patient volume. These contracts offer uniform reimbursement for all patients – regardless of acuity, does not require that you credential every provider, and simplifies billing. However, they may lead to lower care quality and require cash payments for services like follow-up care, vaccinations, and labs.
Fee-for-Service Contracts: Better for clinics seeing more complex conditions and offering diverse services. Providers receive payment for each service rendered and must be credentialed individually. These contracts encourage marketing to new and established patients and may cover ancillaries like labs and radiology services.

Staying Vigilant

Payers may change contract terms to their advantage, so it’s essential to stay informed and vigilant. By understanding and effectively managing payer contracts, healthcare providers can ensure fair compensation and continue to provide high-quality care to their patients.

If you’re looking for assistance with contracting and credentialing, Experity’s RCM services can help. Visit our product page for more information, or fill out the form to have someone reach out to you.

Request Contact From the Team