As many as 100 new urgent care clinics open their doors annually, according to the American Academy of Urgent Care Medicine. In an article published by the Healthcare Financial Management Association (HFMA), author Karin Kaplin writes that urgent care is projected to grow nearly 40%, to $18 billion, by 2017. And with each new clinic comes coding and billing challenges related to high-deductible health plans. Does the patient actually have active insurance coverage? If so, what is his or her specific copayment or deductible for urgent care services? This information is not always printed on the insurance card itself. Most importantly, how can front-end staff members educate patients about the ‘ins and outs’ of these requirements?

Collecting copayments is particularly challenging for urgent care centers that must meet Emergency Medical Treatment and Labor Act (EMTALA) requirements. EMTALA prohibits these centers from delaying screening or stabilization services to inquire about an individual’s payment method or insurance status.

According to CMS, provider-based urgent care centers may be required to meet EMTALA requirements if they are defined as ‘dedicated emergency departments.’ CMS defines these departments as those “held out to the public (by name, posted signs, advertising, or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment.”

Without a clear plan in place to collect copayments up front, urgent care centers subject to EMTALA may find themselves chasing after payments retrospectively. This creates an unhealthy accounts receivable from which it becomes difficult to rebound.


Consider these tips to keep cash flowing

Following are four tips that urgent care centers can use to enhance the up-front collections process:

  1. Provide staff education. Urgent care staff members can’t educate patients unless they, themselves, understand the nuances of various health plans. Can they clearly articulate the differences between a coinsurance, copayment, and deductible? Can they explain to patients why an urgent care copayment is usually higher than that of a physician office visit but lower than that of a ED visit? Create cheat sheets to address general or common questions, and keep insurance phone numbers handy when more specific questions arise. It also helps to get to know your provider relations representatives at each insurance company.
  1. Automate the eligibility process. Do staff members have online access to an eligibility clearinghouse or real-time eligibility tool? Some solutions use a provider’s internal data to estimate the cost of services that will be rendered. This empowers front-end staff to engage with patients about what they will owe and why. These solutions can also predict other details such as the deductible owed, copayment by service level, and lifetime wavers for particular services.

Note that your outsource coding and billing vendor may be able to provide low-cost or no-cost access to these types of tools and serve as a resource for billing questions.

  1. Communicate clearly with patients. This includes re-designing the center’s medical bill so that it clearly states the balance due using an itemized list of services and costs.
  1. Provide payment options. Make it as easy as possible for patients to pay for their urgent care services by accepting credit and debit cards as well as cash.

To learn more about compliant urgent care coding and billing, contact NEMB at 508-297-2068 x232.


About NEMB

New England Medical Billing is a fully HIPAA compliant Medical Billing Management and Administrative Service Firm. Our expertise is in program and system design as well as effective implementation and administration. Our multi-disciplinary approach and attention to detail consistently yields the maximum allowable returns on every client project.

Since 1993 NEMB has been built carefully, approaching each new engagement using proven management methods. Our superior, time-tested approach is applied to each and every engagement. We “zero-base” every new proposal to build a process that fulfills the unique requirements and goals of each project.

NEMB specialists, each of whom has been credentialed by the American Academy of Professional Coders (AAPC), have mastered the coding and billing guidelines pertaining to freestanding urgent care centers. We know what and how to bill services according to payer-specific physician contracts and can help our clients maximize appropriate reimbursement.


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