Urgent Care Insurance Contract Denied? Here’s 8 Smart Ways to Appeal

Your urgent care’s contracting and credentialing team just went through the grueling process of applying for an insurance contract with a payor. They researched the payor’s application requirements and spent weeks gathering and submitting all of the necessary application materials. You thought you crossed all your T’s and dotted all your I’s.

But your urgent care center’s application for an insurance contract was denied. So what do you do?


Luckily, if your urgent care center is denied an insurance contract, it isn’t always the end. Here are eight smart ways you can build a case to appeal the payor’s decision:

  1. Show Network Need: Find ways to show the payor that there’s a need for your urgent care center to be in-network with them. This may be as simple as running a claims report showing how many of the carrier’s patients you’ve treated within the last year. If the number is substantial, it may create an opportunity for you to appeal your application.
  2. Demonstrate Network Inadequacy:
  3. This is going to take legwork on your part, but it could be worth it if it means a potential appeal. Search the network’s provider directory for urgent cares and immediate cares. Document all of the facilities that are included in those categories and where they are located in relation to your center. Note if they are close enough to actually qualify as competition. Then visit those facilities’ websites to see how they are staffed. How does the staffing compare to your urgent care center? Does your urgent care center having any staffing advantages over your competition?
  4. Compare Competitor Services: Check your competitors’ websites again, this time to see what services they offer. Are they retail clinics that only treat low acuity cases like sore throats, or do they offer a full scope of urgent care services, such as fractures and IV hydration? If your competitors are sending higher acuity cases to the ED, they’re costing payors more money, so if your urgent care center serves all acuities, you’ve got a strong negotiating point.
  5. Check Competitor Hours of Operation: Most payors require specific hours of operation for urgent care centers. Make sure your competitors aren’t just primary care offices that are open a few extra hours so they can accept some walk-ins.
  6. Check Competitor Facility Type: Saturation is the most common reason payors deny urgent care contracts. If this is the reason your contract was denied, make sure it wasn’t because of a freestanding emergency department. Urgent care centers and freestanding EDs are not the same type of facility. Freestanding EDs treat higher acuity cases than urgent care centers and charge both a facility fee and a physician fee. Because of this, payors should not consider them competitors when an urgent care center applies for an insurance contract.
  7. Work with Large Employer Groups: Leverage positive relationships you have with employers in your area to get payors to reconsider your application. For example, if you do occupational medicine for a large company in your area, and they have insurance with the payor that denied your contract, ask that company’s human resources department to be a liaison with the payor. The company can communicate to the payor that their employees like your urgent care center so much that they are considering other networks since they are not letting your center in-network. The threat of losing a large client can bring a payor to the negotiating table rather quickly.
  8. Work with a Group of Patients: The same applies to groups of patients, especially if they all work for the same company. Create a form letter stating that the patient would like the payor to add the urgent care center to its network and keep it at the front desk so patients can sign it when they check in at your center. You can then collect the letters and send them in bulk to show the payor there’s significant patient support to bring the center in-network.
  9. Check the “Any Willing Provider” Law: Only 27 states offer some form of law that requires payors to accept any willing provider into their networks. Each state’s version of the law is different, so do your research to see if you can leverage this to help you appeal your application.

In some instances, the payor’s decision to deny a contract is completely legitimate, but in others, research might show there’s a case for appeal. That’s why it’s important to do your research to see if you can build a strong enough case to appeal the payor’s decision to deny your application. Once your contracting and credentialing team puts all of the pieces together from these eight steps, send everything to your insurance rep to see if they’ll reconsider their decision. There are no guarantees, but putting the work in could make a huge difference for your urgent care center.

PV Billing customers have the advantage of an expert team of contracting and credentialing specialists who help you avoid costly mistakes and delays. Not a PV Billing customer? Contact us today!

Subscribe!

Recent Posts