Anyone who has started a successful urgent care center will tell you it’s critical to have timely execution of urgent care credentialing, contracting, and billing.
Contracting is the process of negotiating and signing agreements for an urgent care center to become a “participating provider” with a health plan. Health plans may choose to contract with a provider, a group, or a facility. Credentialing is the process of submitting provider credentials to a contracted health plan for verification.
Contracting and credentialing takes time; we recommend you begin the process 6 to 8 months before opening day. It can take 30 to 100 or more days to receive a contract from a Managed Care Organization (MCO) or payor. The credentialing process will take 180 days or more, and activation can take another 30 to 60 days, as the payor loads the contract into their system and an effective date is issued.
If you have worked in the same area as your new urgent care previously, chances are you will want to pursue the payors you already know. On a national level, start with the large national commercial payors and Medicare. Ask hospital billers, local physicians and urgent care billers in your area about the possible advantages and drawbacks of joining an MCO. Remember, you can’t force an MCO to talk with you. They must believe that negotiating with you is in their best interest.
When negotiating your payor agreements, watch for the following: MFN clause, which products are included, initial term, discounts on mid-level delivered services, and case rate versus fee for service. And don’t forget to ask about billing requirements regarding POS, Group NPI, rendering provider NPI, special modifiers for mid-levels, and whether mid-levels should bill independently or under the supervising MD/DO.
Whether you are planning to do your urgent care billing yourself or contract with an expert urgent care billing organization, familiarize yourself with ICD-9/ICD-10, CPT and HCPC coding and the impact that accurate coding has toward the success of your urgent care center. ICD stands for International Statistical Classification of Diseases and Related Health Problems, which are often referred to as diagnosis codes. ICD-9 codes are currently used, with implementation of ICD-10 now expected on October 1, 2015. Current Procedural Terminology Evaluation and Management (CPT E/M) codes from 99201-99499, are used to describe patient visits in broad categories. Healthcare Common Procedure Coding System (HCPCS) codes describe health care procedures based on American Medical Association standards.
To ensure the financial success of your urgent care center, it will also be important to understand Electronic Data Interchange (EDI) and Electronic Remittance Advices (ERA) which allow providers to submit claims and receive payment information electronically. Additionally, the ERA helps maintain good billing processes including provider and insurance setups, working payor rejections, the 60-day refund rule, and timely filing requirements. Urgent care billing is complicated, but understanding the details is critical for you to be paid appropriately for the work performed in your practice.
To learn more about contracting, credentialing and urgent care billing, call on the experts at Practice Velocity, 888-357-4209.