In the past 20 years or so, a number of specialty clinics have emerged which have gone well beyond the general services offered by urgent care facilities or other standalone clinics. When they first appeared, many of these specialty clinics focused on men’s health and women’s health. Unlike other generalized clinics, these specialty clinics did not really treat acute healthcare conditions, and also did not focus on the typical wide range of medical conditions which patients might have.

Instead, many of these clinics initially focused on sexual health and the treatment of sexually transmitted diseases, erectile conditions, and the diagnosis and treatment of fertility. Patients tended to be individuals in their middle years with private health insurance who wanted to maintain or improve their sexual vitality. These specialty clinics arose primarily in suburban areas which were very close to their patient demographic, and they were not in direct competition with hospital care or with primary care practices.

Since their first appearance, specialty clinics have evolved and expanded, so that their main offerings now are not improved sexual health, but rather services which focus on youthfulness and vitality. Given the fact that overall vitality will generally make a significant enhancement to sexual, athletic, and intellectual performance, many specialty clinics now provide a wide range of vitality options and services. Some of these services even include aesthetic and appearance programs designed to make patients feel better about themselves.

Medical billing claims for specialty clinics

As you might expect, medical billing for specialty clinics can be different from claims submitted for standard healthcare services. The first thing that is necessary when filing claims for specialty clinic billing is to have a thorough understanding of which services can be legitimately claimed and which ones cannot. Referrals and prior authorizations are a key component of specialty services. Some of the services provided by specialty clinics are considered optional and are merely self-improvement services desired by the patient.

Many of these will not be allowable because they won’t be covered by insurance carriers. If there is no legitimate medical need, many insurance carriers will reject a claim outright. This makes it extremely important that any specialty clinic identify all those services which are allowable via various insurance carriers, and those which are not.

It will be a waste of your time and effort to submit medical billing claims which will not be honored by a given carrier. This means it’s also important for you to know which services are treated as allowable by specific insurance carriers. When you have a good understanding of which services are allowable by any insurance carriers you work with, you’ll be able to submit medical billing claims for your specialty clinic with a reasonable expectation of being reimbursed.

Additional factors

Given the fact that there are gray areas in insurance coverage for specialty clinic medical billing, it can be a difficult to stay abreast of all the appropriate codes which would be used for allowable claims. To complicate matters, it’s often very difficult for billing departments of a specialty clinic to keep current with technology and changes in the industry, not to mention insurance carrier requirements.

This can result in all kinds of delays for being reimbursed on medical billing claims, and this is why many specialty clinics prefer to outsource the task to acknowledged industry experts who manage to stay abreast of all recent changes and developments. Anytime you can minimize delays or outright rejections, your cash flow will be much improved, and you won’t find yourself on the hook for services provided which you don’t get reimbursed for.

You can help yourself out a great deal by thoroughly familiarizing with all the appropriate codes specific to those services administered by your specialty clinic. If you’re working with a third party on these medical billing claims, they are probably already aware of what those specific codes are, and will make use of them on any claim submitted on your behalf. 

The ultimate goal for any specialty clinic would be to know in advance which services they provide can be reimbursed by a specific insurance carrier, so that the chances of reimbursement are improved. Otherwise, it would be advisable to inform your patient that the service will not be covered under their insurance plan, and that they would have to pay for it out-of-pocket.


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