Urgent Care Billing: In-House or Outsource?

1. Contract negotiations: Where is your urgent care center going to find someone who is completely versed in what the payors are actually expecting in urgent care negotiations? Kelly Mattingly, Director of Contracting and Credentialing for PV Billing says, "It tends to go smoother each time we call the same provider representative for a particular payor. We know (and they know we know) what possible contract terms are available. It really does help get the best possible rates and terms much more quickly."
2. Credentialing: If a particular payor requires individual credentialing of providers, you need an expert to fill out this paperwork. The process often takes almost six months (180 days is the NCQA standard), but even one small mistake and your provider can end up out of plan for many additional months.
3. Coding: Many (in fact, almost all) urgent care centers lose out on 10-20% of revenue simply because they are not aware of the critical importance of coding correctly.
4. Compliance: We have talked with other urgent care professions who have spent hundreds-of-thousands of dollars to defend themselves against coding audits. If you have software that gives an automatic audit trail for every code on every chart, a simple audit generally involves an auditor looking at 10-20 charts; and the audit is done.
5. Claim submission: How do you submit claims for Medicare, Humana, United Healthcare, Medicaid, Workers Compensation, Employee-Paid Services, and many other payors and visit types? It is truly amazing how many times we get calls from billers with these very basic questions. An expert urgent care biller already knows the answers.
6. Claim formatting: Believe it or not, a single incorrect digit, code or field in a claim, and the claim will fail. You need a biller who understands how to avoid these denials, and when they do happen (and they will happen) how to fix the formatting and submit the claim on a timely basis.
7. Collections: Dealing with portions of a claim that becomes patient responsibility is very complex. Do you have a way to require and automate credit card billing even months after the patient visit? If you do, this can increase collections on these accounts by an additional 60-90%. If you don't then your collections from these patients will amount to less than 50% of the portion that is their responsibility. Does your team know how to bird dog accounts in a systematic way? Does your team know when to turn an account over to a collection agency? Before picking an outside billing company to perform billing services for your urgent care center, make sure that you are satisfied with how that biller answers these questions.

• Scarcity: Very few experts in urgent care billing even exist. Can you really find and hire an employee with true expertise in every area of urgent care billing listed. Owners of established, multi-site urgent care centers often complain to me that even they can't find these experts.
• Risk: Another problem with hiring your own biller is that it fails the single-point-of-failure test. Of course, no one wishes for a staffer to fail or leave, but many urgent care centers end up losing their biller to illness, injury, termination or resignation. The center often gets months behind in revenue cycle management. In recent years, we are aware of several otherwise-successful urgent care centers that have failed or almost failed due to losing their biller. Ouch!
• Cost: So you were lucky enough to find a true expert in urgent care billing. But watch out, that person will likely demand a salary outside of a reasonable range for the budget of a typical single urgent care center. In addition, the cost of being wrong about the biller's expertise and execution may result in hundreds-of-thousands of dollars in lost revenue.

• Simplicity: Urgent care executives need to focus on the many details that cannot be outsourced. An expert urgent care billing company allows these executives to focus on marketing, quality, training, performance, human resources and all of the myriad elements of operating a quality urgent care center.
• Expertise: Rarely can an urgent care center find a single urgent care billing specialist with an adequate fund of knowledge in the seven C's of urgent care billing.
• Stability: When a biller at a large urgent care billing company leaves, someone else steps in and keeps your accounts receivable up to date. When your own single employee biller resigns, you may get several months behind in collections. This can result in financial difficulties or even financial failure of the center.
• Contracting: A generalist biller might have some general experience in contracting with payors. But rarely does a generalist biller have significant experience with contract negotiations for urgent care centers? Even many medical billing companies won't have access to anyone with urgent care contracting experience. Even more unlikely will be that they have recent urgent care contracting experience-and that is the only experience that is relevant, because most payors are completely changing their contracting methods and terms for urgent care.
• Risk Management: If you fail at billing, your center will fail. Why take a chance on doing your own billing, when this is the critical point of failure for so many urgent care centers? Why not work with an urgent care billing company that has a track record of success.

» left by florestilleys

from Rockford, IL 2 years 290 days ago.

Very informative!

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» left by Jack Wilson

from San Jose, CA 2 years 91 days ago.

This is very useful information.  We tried doing our own billing, but we ran into problem after problem.  When we finally turned to expert urgent care billers, using excellent urgent care software, we had much more financial success.

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