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Working with insurance companies is rarely simple, and when it comes to payer reviews, you may only have one chance to get things right. With payers scrutinizing claims more than ever before, urgent cares are worried about what that means for their bottom line and what they need to do to prevent rejections and denials.

This guide explains three different payer reviews — pre-payment, post-payment, and probe — along with steps to take in each situation. While there is an ascending level of concern associated with these, you should always take payer reviews seriously and address them promptly.


Pre-payment reviews occur when your practice’s claim data is analyzed by the payer and a provider has been identified as an outlier. For example, Dr. Jones is billing more level 4s than other providers of the same specialty in your area. Practices are notified by letter stating which provider and which codes will require a review prior to adjudication of the claim with the date the pre-payment review takes effect. Claims for the provider with codes under review require the medical record be included at the time of initial claim submission. Failure to submit the medical records will result in a claim denial and further delay in payment.

Payers review the medical record and either adjudicate the claim if they agree with the coding or deny if they disagree with the coding. Often, a practice will receive detailed letters as to why the reviewer did not agree with the coding. Resources for education may be included.

The payer will take the practice off pre-payment review when the payer has received a specific volume of claims with a specific threshold of accuracy. For example, the practice must submit 500 claims with an accuracy threshold of 95%.

Level of concern: Low 

What should I do?

  1. Work with your billing team to make sure the initial claims are being submitted with medical records. Make sure they have the criteria of which claims require medical records. It won’t be 100% of your visits.
  2. Ask the reviewer what threshold and volume of claims are required to satisfy pre-payment review. Call the number on the pre-payment review letter, not the regular claims representative number. Most likely the claims representative will not know that your practice is on pre-payment review.
  3. Compare your data to other urgent cares. If your billing team doesn’t have this data, consider reaching out to a consultant.
  4. Look at your results and identify claims to appeal or areas for improvement. Be objective. The insurance plan will not always be right, and neither will your practice. Choose the claims to appeal wisely. If it is a gray issue where you can see the payer’s point, it may be a better idea to submit a lower-level code for payment.
  5. Be proactive. Take the results, after your medical team reviews, and educate providers on how they might improve their documentation to properly reflect the level of care delivered.

If you have been on a pre-payment review for months, reach out to the payer to see what can be done. The practice may need to change their behavior to see better results. This doesn’t necessarily mean lower your levels, rather you may need to improve your provider documentation.


Post-payment reviews are routine actions by a payer. Medicare or Medicaid managed care products are required to do a review of claims for the Centers for Medicare & Medicaid Services (CMS) or your state Medicaid program to verify the payer is adjudicating the claims correctly. Dates of service will fall in the prior year or even earlier. The payer may ask for monies back if they conclude the coding was incorrect. For government payers, the amount may be extrapolated to your entire volume of claims for that payer, resulting in large refund requests.

Post-payment reviews come in the form of a letter with a listing of claims for which the practice must submit records. Pay attention to the deadline in the letter. Failure to provide documentation will result in the payer requesting their payment back. A payer may give you only one appeal opportunity, so it’s better not to squander that opportunity with having to prove your practice performed the service. Rather, use the appeal to defend your coding.

Level of concern: Moderate

What should I do?

  1. Pull the records and submit by the payer’s deadline. Include all supporting documentation (i.e., laboratory results or radiology reports).
  2. Be patient. It may be longer than six months before you hear the results of the review.
  3. Review every claim that the payer counted as an error. If the number of claims is high, consider using an external auditor with experience in urgent care to perform this review.
  4. Involve your medical team. The current Evaluation and Management (E/M) guidelines were written for medical providers and can be subjective. For example, take the element “Risk of Complications and/or Morbidity or Mortality of Patient Management”. The American Medical Association (AMA) offers little guidance beyond a few examples in their medical decision-making matrix. However, these are not meant to be absolutes. Ultimately, the management risk is what is understood by providers of your same specialty. The individual that reviewed the claims for the payer may have no experience with urgent care. This is where the medical team can assist with identifying the visits to appeal and the rationale for your appeal.
  5. Pay attention to the appeal deadline. If you need more time, call and request an extension from the special investigator listed on the letter.
  6. Negotiate. Your practice may have to send some amount back to the payer. However, usually the payer will ask for the full payment back. If the payer has agreed that your practice was entitled to payment yet at a lower level and you agree, offer to send back the difference only.
  7. Use this as an opportunity to improve your documentation and educate your providers.


Probe reviews happen when a payer notices an unusual pattern in your claims data. The letter you receive will look similar to a post-payment review letter. The dates of service will be current, however. The letter may even say it is a probe review. Usually, these are provider-, not practice-, specific.

Level of concern: High

What should I do?

  1. Pull the records and get them to the payer by the deadline in the letter.
  2. Don’t wait for the payer to send you the results. That could be months. Have a coding/billing expert review the sample of claims requested to identify any red flags.
  3. Research and, if needed, correct any mistakes that your expert identifies on a go-forward basis. Claims that have already been billed should be addressed with the special investigator at the insurance plan after the results are received.

Bottom-line: Don’t panic! Take these reviews seriously. Be organized and perform your own review focused on defending your coding, where applicable, and creating a learning opportunity for provider documentation and coding/billing processes going forward. Be prepared to respectfully advocate for your practice.

Physician document patient visit

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What Else can I do?

Obviously, tightening up your billing practices can help you minimize payer reviews and be better prepared when they do occur. However, provider habit are often the reason for unusual patterns in claims data and other reasons for a review. Without the right analytics, it can be complicated to get visibility into E/M weights and other coding issues.

Furthermore, your odds of accuracy are much higher if you have help identifying potential concerns. Here are a few proactive steps you can take to improve your claims.

Improve your first line of defense

You are the first line of defense — you should know what’s going on at your practice, understand how to identify issues, and provide guidance/education to rectify and prevent mistakes.

This all starts with data. Your PM should provide reports that help you see what’s happening at your clinic. If you aren’t diligent about running routine reports for insights, you should start now.

If you already rely on data from your PM, but find it is still difficult to get what you need, you may be a good candidate for a business intelligence solution. This will simplify your data collection and review process – and also let you track more granular, specific details quickly.

Schedule regular internal coding audits to find inaccuracies and outliers that could indicate more education is needed. Remember, these audits will not only identify where you may be inaccurately upcoding but can also show if providers are under coding visits, lowering potential revenue.

Improve your second line of defense

If you’ve chosen to work with a third-party biller, they should be able to catch some unusual patterns and other discrepancies before submitting your claims. If your billing partner does not understand urgent care-specific issues and red flags, you may need to consider a new partner. If you do billing in-house, this comparison piece can help you decide if it’s time to recruit help:  In-house vs Outsourced Billing in Urgent Care: Pros and Cons