urgent care billing mistakes

Urgent care billing mistakes won’t just cost your center a few cents off the dollar. They can be extremely costly – sometimes even at the expense of the success of your center.

These are the seven worst urgent care billing mistakes you probably didn’t know you’re making:

Mistake 1: Negotiating bad contracts or not having contracts at all

Setting up contracts with payers creates a legal agreement that the payer will market your urgent care center as in-network in the payer’s network directory and reimburse your center per the contracted fee schedule. If you don’t set up contracts with payers in your area by the time your urgent care center opens, you won’t be able to accept any insurance. That’s one urgent care billing mistake that makes it almost impossible to build the patient volume you need to break even.

Negotiating low reimbursement rates with payers isn’t much better because you won’t get paid much for the services you render to patients. The contracted rates need to be fair and reflect the scope of services that your urgent care center provides.

How to fix it: Hire a contracting expert to negotiate your payer contracts for you. A contracting expert will know the best reimbursement rates for your area and will ensure you avoid costly mistakes and delays.

Mistake 2: Not following credentialing guidelines

Many people think contracting and credentialing are the same, but the two are very different processes. Credentialing is the process through which a payer verifies a provider’s experience, expertise and qualifications to ensure the safety of patients. Each payer has its own credentialing requirements, so don’t make the mistake of assuming no credentialing is needed because one payer didn’t require any credentialing. Unless you have facility contracts, having payer contracts isn’t enough. You need to make sure your providers are connected to the payers for your practice so the claims process correctly.

How to fix it: Hire a credentialing expert who can help you navigate payor credentialing requirements.

Mistake 3: Accidentally committing “locum fraud”

Clinics have a lot of questions about appropriately billing for outside providers working temporarily at their clinic. Just because a mid-level provider or nurse practitioner comes from a locum agency does not mean they can be billed under the locum guidelines. By definition, a locum tenens is a physician covering for another physician. For some payers, such as Medicare, mid-level providers are paid 15 percent less than physicians, so billing a mid-level under a physician is not only inappropriate but could result in the payer reimbursing you for more than they should be. You’d also be committing fraud.

How to fix it: Only bill physicians as locum tenens.

Mistake 4: Missing steps at the front desk

Is your staff asking all the right questions when a new or established patient walks in the door? If you haven’t confirmed current insurance information for a patient before they leave your clinic, the chance of getting this information later is significantly reduced. Not ensuring coverage combined with not collecting copays, reduces the chances of collecting a full payment. Following up with patients to get missing information takes time, and patients aren’t likely to be in a hurry to respond. This can slow down your claims process, and ultimately, reimbursement.

How to fix it: Opt for a PM solution that offers real-time insurance verifications so you can identify potential billing problems up front. And always collect a copay at registration. Also, be sure all paperwork is accurate before it heads to the billing department.

Mistake 5: Not knowing (and following) the 2021 E/M guidelines

2020 and 2021 were years of big change when it comes to E/M coding and regulatory updates. During the pandemic, new CPT codes were introduced to help clinics manage COVID-19 testing, telehealth visits, and vaccination administration. And in January of 2021, E/M coding guidelines were drastically updated in order to support providers. If your staff is not up to speed on how to code in light of the changes, you could be leaving money on the table. In addition, your claims may inaccurate, resulting in rework and delaying reimbursement.

How to fix it: Establish good financial processes starting at your front desk and make sure all staff is trained on those processes. Hold re-training on a regular basis to ensure those processes are always followed.

Mistake 6: Incorrect documentation

great urgent care EMR is only as good as the provider who is using it. If providers aren’t documenting for all the services they provide, capturing ancillary services, and using the right modifiers in the correct section of the EMR, it can result in lower clinic revenue. Billers should have a deep understanding of payer guidelines to ensure your claims are clean. Having a coding specialist, whose job includes checking and verifying codes before they are submitted, can be a huge help in reducing errors, and ultimately, getting paid accurately for the services you provide.

How to fix it: Providers went to medical school to learn how to treat patients, not how to learn how to code, so your chief medical officer and office manager should work with your billers or urgent care billing service to develop a quality assurance process to ensure providers are educated (and re-educated as appropriate) on how to use the EMR correctly.

Mistake 7: Not filling out the claim correctly

Filling out a claim can be a bewildering process, and both omitting pertinent information from a claim or including unnecessary information on a claim can get a claim denied. Some payors, for example, require the National Drug Code (NDC) documented on the medical record in a specific format. Others, however, don’t require the NDC but will deny the claim if the NDC is included in a format different from the payor’s preferred format. Confused? You’re not alone.

How to fix it: An expert urgent care billing service will know how to navigate the intricacies of claim submission so you avoid denials.

Avoid urgent care billing mistakes for good

Correcting these urgent care billing mistakes can mean significant increases in revenue for your center. If you’re not sure if your center is making these mistakes or you need help correcting them, it can be helpful to seek the advice of a professional urgent care billing company that has expert knowledge of urgent care revenue cycle management.

Experity’s EMR/PM was built to take some of the guesswork out of coding with recommendations updated to reflect the newest E/M coding guidelines from the Centers for Medicare and Medicaid Services. If you feel like you’re missing out of revenue you should be getting, our Revenue Cycle Management (RCM) team helps clinics across the country improve their financial results with best-practices and expertise – and stay compliant.

Schedule a free consultation with our team to identify bottlenecks, explore claims challenges, and identify faster options.