The 7 Worst Urgent Care Billing Mistakes You Probably Didn’t Know You’re Making

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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 payors creates a legal agreement that the payor will market your urgent care center as in-network in the payor’s network directory and reimburse your center per the contracted fee schedule. If you don’t set up contracts with payors in your area by the time your urgent care center opens, you won’t be able to accept any insurance. That can make it exceptionally hard to build the patient volume you need to break even.

Negotiating low reimbursement rates with payors 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 payor 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 payor verifies a provider’s experience, expertise and qualifications to ensure the safety of patients. Each payor has their own credentialing requirements, so don’t make the mistake of assuming no credentialing is needed because one payor didn’t require any credentialing. Unless you have facility contracts, having payor contracts isn’t enough. You need to make sure your providers are connected to the payors 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”

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 payors, 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 payor 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: Not Fixing Bad Front Desk Processes

One big mistake many urgent care centers make is not having good financial processes at their front desks. You need to be diligent about collecting copays at the beginning of visits instead of the end of visits and collect on prior balances before rendering new services. If you don’t have these processes in place, you run the risk of adding to your A/R, losing out on revenue, increasing your bad debt, and increasing the number of patient accounts you send to collections. You’ll also end up with the reputation as the urgent care center that doesn’t make patients pay their bills.

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 5: Not Understanding Pass-Through Billing in Contracts

Do you know which of your payor contracts prohibit pass-through billing (also known as purchase service billing)? Pass-through billing means you cannot bill for a service that you did not personally render. For example, if you use a reference lab to send certain labs out, and the reference lab actually runs the test, you can’t bill for that lab if the payor doesn’t allow for pass-through billing. In that case, the reference lab needs to bill for those labs. More and more payors are starting to add language stating that they won’t reimburse for pass-through billing, so it’s important to understand when you can bill for that.

How to fix it: Your urgent care billing service can help you understand whether your contracts allow you to bill for pass-through billing services.

Mistake 6: Under-Coding Charts or Documenting Incorrectly

A great urgent care EMR is only as good as the provider who is using it. If providers aren’t documenting in the correct section of the EMR, it can result in the service not being coded out, resulting in missed revenue for your urgent care center. It is also crucial for providers to correctly document the history, exam and MDM in the EMR to make sure the office visit codes accurately reflect what the provider did during the office visit.

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 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.

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 mistake 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.

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PV Billing produces higher revenue for urgent care centers across the U.S. That's more than $18 of additional reimbursement per visit (compared to UCAOA annual survey data).

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