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The central aim of an urgent care clinic is to provide immediate medical attention to unscheduled, ambulatory patients dealing with acute or episodic illnesses or injuries. Urgent care centers provide accessible and timely healthcare services for various non-life-threatening medical concerns outside regular office hours, including evenings and weekends. Due to the often urgent nature of their operations, these centers may face time constraints, leading to the potential for clerical errors, data entry inaccuracies, or lapses in coding and documentation, significantly impacting medical billing and the revenue cycle. Utilizing outsourced urgent care medical billing services has emerged as a viable strategy to mitigate these risks, enhance accuracy in urgent care billing processes, and ensure optimal reimbursement.

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Reasons for Higher Risk of Medical Billing Errors in Urgent Care

In addition to time sensitivity of their operations, there are many reasons why risk of medical billing errors is relatively higher in urgent care centers:

  • Variety of services: Urgent care centers offer varied services, from basic primary care to minor surgeries and diagnostic tests. Managing the billing and coding for this broad spectrum of services can increase the complexity and risk of errors.
  • High patient volume: Urgent care facilities typically see a significant number of patients daily, especially during peak hours. This can pose a challenge for billing accuracy.
  • Quick turnaround: Fast claim processing is necessary to ensure prompt reimbursement, leading to increased risk of coding errors, data omissions, or oversights in verifying insurance information.
  • Incomplete patient information: Urgent care providers might not always have access to a patient’s complete medical history, which can lead to inaccuracies in diagnoses, treatments, and coding.
  • Various insurance providers: Urgent care centers often deal with a diverse payer mix, each with unique billing requirements, coding standards, and reimbursement rates. If billing staff are not well-trained or if systems are not properly integrated, managing this diverse payer mix can lead to errors.
  • High denial rates: Urgent care centers may experience relatively high denial rates for insurance claims due to the variety of services offered and the complexity of coding. Managing denials and appeals can be time-consuming and error-prone.
  • Lack of trained billing staff: Without trained and experienced billing staff, urgent care clinics can find it challenging tostay current with constantly changing medical billing rules and regulations. This can lead to potential errors in documentation and coding.

The billing process for urgent care services typically involves several steps to ensure accurate and timely reimbursement for the medical services provided. If these steps are not followed correctly, it can lead to billing errors and loss of revenue.

Common Billing Errors in Urgent Care

  • Flaws in front desk processes: The revenue generation process begins when the patient arrives at the center. The patient registration needs to be completed correctly, where the staff has to collect the individual’s personal information, insurance details, and signature on necessary consent forms. Insurance eligibility verification is a must to determine the patient’s eligibility for urgent care services. Front desk personnel need to collect co-payments from patients before proceeding with new services. This is essential to minimize chances of partial or non-payment following provision of services. Oversights and errors at the front desk can lead to revenue loss due to outstanding debts and can also hinder the timely submission of claims.
    • Absence of payer contracts or inadequate payer contracts: Payer contracts in healthcare set reimbursement rates, often negotiated between providers and insurers, ensuring predictability in revenue. They are legally binding, outlining terms, reducing billing disputes, and ensuring smooth claims processing. Furthermore, providers need to strive to negotiate favorable payer contracts that align with their financial goals and support the delivery of high-quality care to patients.

Without a payer contract, providers might receive lower payments or have no agreement on rates at all. Moreover, they should steer clear of payer contracts with unreasonably low reimbursement rates for medical services. Such contracts can result in financial losses if they do not adequately cover the high costs of services provided. Contracts that limit the provider network or exclude key healthcare facilities can also hinder patients’ access to care. Limited network adequacy can reduce patient volumes and revenue for providers.

Urgent care providers must make sure to sign payer contracts. Identifying and addressing “bad” payer contracts is also essential for protecting the financial viability of healthcare organizations and ensuring patients receive the care they need. Urgent care centers require equitable negotiations that reflect the quality of care they offer in order to obtain higher reimbursements.

    • Coding errors: After the medical services are provided, providers document the details of the patient’s visit, including the diagnoses, treatments, and procedures performed. This information is used to assign appropriate medical codes, such as CPT codes and ICD codes, which accurately represent the services provided. Urgent care centers provide timely care for a wide range of conditions including but not limited to: minor injuries, colds, flu, ear infections, urinary tract infections (UTIs), gastrointestinal issues, allergies and allergic reactions, skin rashes and infections, fever, headaches and migraines, nausea and vomiting, diarrhea, dehydration, and chronic condition management. They also provide preventive and diagnostic services including vaccinations, X-rays, basic lab tests, physical exams, and pregnancy tests. Minor procedures performed in urgent care centers include Suturing or stitching of wounds, splinting for minor fractures or sprains, and incision and drainage of abscesses, and.

Urgent care centers must stay updated on billing and coding changes related to these conditions and services. Errors in specialty-specific codes can lead to payment delays and denials. The emphasis should also be on error prevention, including appending essential modifiers and accurate diagnosis and procedure codes.

    • Inadequate or erroneous documentation: The majority of EHR systems incorporate software designed to assist healthcare providers in determining the suitable evaluation and management (E/M) CPT codes for patient visits. When utilized correctly, these tools facilitate precise coding grounded in medical necessity and have been linked to generally increased levels of E/M coding accuracy.

If an EHR system cannot document crucial E/M-related details in a structured manner, it has the potential to cause documentation errors and recommend E/M codes that undervalue what should have been recorded, ultimately resulting in revenue loss. Serious EHR software design flaws, insufficient implementations, and a general lack of user knowledge regarding how the E/M coding systems function can lead to errors in EHR documentation, impacting both patient care and reimbursement for urgent care centers.

    • Missing charges: Neglecting to properly account for charges can lead to financial losses for healthcare facilities, such as urgent care centers. This issue often arises due to incomplete documentation, which is particularly prevalent in busy and high-demand environments like urgent care centers. Handling numerous patients simultaneously can place a significant burden on staff, increasing the likelihood of errors and omissions in the documentation process. It’s important to recognize that in healthcare billing, each step is typically billed individually. Therefore, any mistakes or omissions can result in delays in claims submission and even claim denials.

One effective approach to address this challenge is to empower staff to remember and recognize common missed charges. By identifying these frequently overlooked items, staff members can proactively work to ensure they are consistently included in the documentation and billing process.

Additionally, implementing a rigorous double-checking system can be highly beneficial. This involves having a second set of eyes review the documentation and billing before submission. This extra layer of review can catch errors or omissions that may have been missed during the initial documentation process, thereby reducing the likelihood of costly mistakes.

Preventing overlooked charges is critical for the financial health of healthcare facilities like urgent care centers. By raising awareness among staff, promoting vigilance in documentation, and implementing thorough review processes, facilities can minimize the risk of errors and the associated financial impact.

To mitigate these risks, urgent care centers should invest in proper staff training, implement robust billing software and systems, conduct regular audits, and stay updated with industry changes and compliance regulations. Managing the tasks associated with urgent care billing can be exceptionally challenging. Moreover, maintaining compliance with ever-changing rules and regulations poses another formidable challenge for physician facilities. Given the industry’s rapid evolution, coding for urgent care medical billing presents unique complexities. Consequently, handling these procedures internally is not advisable. Outsourcing medical billing to specialized companies can help reduce errors and improve revenue cycle management.

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Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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