In urgent care practice, there is an escalating demand for urgent care providers to treat more patients, render more complex quality services, and complete accurate and comprehensive documentation professionally and efficiently. This spares minimal or no time for a flawless billing and coding process. Yet, urgent care coding and billing are integral parts of practice management that directly influence urgent care establishments' financial stability and legal compliance. Besides other challenges such as efficiency, time management, and professionalism, the shifting towards value-based reimbursement has added more complexities in streamlining the billing process. To financially boost or sustain urgent care practice revenue, healthcare practitioners must have mastery and tips to simplify the billing process at every patient encounter. As urgent care practitioners always stay busy, and it is evidenced that overworked practitioners generate less revenue, the best solution to this concern is outsourcing urgent care billing and coding to a trustworthy urgent care billing and coding company such as MedsIT Nexus.
Urgent care billing is the process of submitting and following up on claims submitted to insurers to get reimbursement for the treatment and services rendered by an urgent care facility. CMS categorizes incorrect billing as fraud; therefore, streamlining urgent care billing is essential. Studies show that implementing quality improvement strategies for documentation, coding, and billing will assist the healthcare system in generating maximum revenue. Let’s dive into the depth of advantageous tips.
Electronic billing systems have proved to play an essential role in discovering the billing system's
bottleneck. Here are some of the crucial tips.
Integrate EHR:
One of the benefits of EHR is "Automation," which can be described in a way that they are super
beneficial tools by automatically generating invoices and processing payments, which means there will be
fewer manual tasks, fewer errors, time-saving, and better communication with payers. Another benefit is
called "Standardization," which means EHR organizes patients' records uniformly and consistently, along
with billing codes following the same format to simplify everything.
"Centralization" is also an advantage of implementing EHR, depicting that all the data and records are
stored in one place, eliminating the likelihood of scattered paper records.
Moreover, it improves data accuracy by reducing manual tasks and eliminating human errors. The most
important factor, i.e., data privacy, is enhanced by this system, ensuring compliance with HIPAA
guidelines and health information exchange (HIE) from healthcare providers to billing departments to
insurance companies through controlled and auditable provider access. The researchers in Massachusetts
found that 6.1% of healthcare practitioners who use EHR have paid malpractice claims in contrast to
10.8% of healthcare practitioners who do not use EHR; the main reason for this reduction is
communication, appropriate medical records, and improved adherence to guidelines.
According to the Journal of Health Information Management, various literature reviews on implementing
computer-based patient records (CPR), first implemented in 1991, show that it provides administrative,
clinical, revenue enhancement, and workflow advantages.
Electronic medical record (EMR):
Some authors say it is a significant and essential initiative to employ EMR due to its benefits, such as
better patient services, reduced cost, and improved outcomes.
Electronic claim submission:
An efficient claim billing system is necessary to navigate the challenges associated with claim
rejection. Therefore, electronic claim submission paves a smooth path by providing various pros such as
faster claim processing, increased accuracy, better workflow, reduced cost, and improved cash flow.
The front-end process of your urgent care RCM encompasses the tasks that are performed before or at the point of service, such as:
There has been increased adoption of value-based payment in the past decade, hence growing opportunities to reimagine pre-authorization as a more collaborative and value-enhancing process. A journal evidences that clinicians and physicians are frustrated and exhausted because of the time, money, and energy required for pre-authorization; however, implementing pre-authorization by practitioners typically provides guideline-adherent provision of individualized, safe, and new therapies. The insurance verification process ensures the verification of the following:
This process can be done by implementing an Electronic verification tool.
As a healthcare provider, you must know that healthcare insurance policies do not always cover
everything; therefore, patients will be responsible for paying for uncovered services. However, direct
out-of-pocket payments (OOP) cause concern and poverty among many developing countries. This can
threaten urgent care facilities; therefore, urgent care providers need to collect copayments for better
optimization of the revenue cycle by implementing well-designed policies and strategies given below.
Focus on payment at the time of service: When it comes to collecting payment at the
time of service, developing an upfront payment policy is the norm for success because it reduces the
challenges of collecting remaining payment and overhead expenses. This policy should be written
formally, shared via emails or hard copies to inform patients, and signed by the patient. The policy
must comprehensively comprise the information such as:
Implement patient responsibility form: The patient responsibility form is printed paper
that, when signed, reflects that patients agree that they are obliged for finances/charges not covered
by insurers.
Double down front-desk team training: As your front-desk crew is primarily responsible
for collecting payment upfront, therefore they should be trained enough about payment policy and some
other important sections such as:
Provide different digital payment options: It is essential to understand that only some patients submit payment upfront and by cash; keeping this and the modern era in view, offering patients various digital payment options is beneficial.
The back-end process of your urgent care revenue cycle management involves the tasks performed after
providing the services, such as coding, claim submission, billing, and collections.
Stay Updated with Coding: Guidelines for coding using ICD-10-CM, S codes, and CPT codes are set forth by CMS, AAPC, and the National Center for Health
Statistics (NCHS). The current billing and coding procedure set forth by CMS depends on E/M codes, which
allows insurers to provide fee a fee-for-service reimbursement approach. Therefore, keeping yourself
updated with every code change and their guidelines and imply codes according to POS-20 to ensure
accurate coding. For this purpose, be sure that your staff is well trained and certified by authentic
organizations such as AHIMA and AAPC. Motivate your staff to earn the latest certifications to enhance
skills and knowledge about current urgent care coding. Moreover, a step to clean claims is to avoid
upcoding and downcoding because upcoding is considered detrimental, while downcoding at non-profit
healthcare organizations accounts for extreme revenue loss.
Clean Claim Submission and Follow-Up on Claims: A comprehensive clean claim with all
information, such as diagnosis, treatment procedures, and charges, brings smoothness to billing.
Furthermore, time is the key to reimbursement in billing, therefore claims must be submitted before the
deadline using electronic claim submission. Keep an eye on claims that have yet to be reimbursed by
sending reminders through messages, phone calls, or emails.
Regular Audit: Medical organizations, particularly urgent care facilities, prioritize
audit as a quality improvement (QI) approach by avoiding loopholes and employing tactics for betterment.
Hence, if you don't conduct audits in your billing & coding, your RCM cannot flow smoothly because
audits are considered to escalate accountability and optimize the quality through systematic monitoring
and evaluation.
The types of audits implemented to determine areas of improvement include:
| External audits | External audits, also called Recovery Audit Contractors, are conducted by someone who is not an internal auditor to overcome the challenges of fraud and identify if there is any improper payment made on any claim. |
| Internal audits | They are performed by the healthcare facility's staff member/auditor to identify the threats so that actions can be taken before any issue arises. |
| Clinical audits | They concentrate on improving particular areas of urgent care to detect risks and help employ improvement plans. |
| Random audits | This can be an external or internal unsystematic audit that helps the organization address significant potential threats. |
| Commercial payer audits | They focus on a particular code group, specific billing patterns, compliance with payers' rules, |
| Prospective audits | You will conduct these audits before claim submission to control data collection; however, it may be costly and time-consuming. MACs typically conduct this audit on claims to check if documentation supports billed services. |
| Retrospective audits | They are conducted after claim submission to uncover new heights |
The critical components of the medical billing audit checklist in urgent care include claim accuracy, compliance with regulation, coding practices, documentation quality, denial management, reimbursement accuracy, and internal controls.
| Urgent care audit checklist |
| Is patient demographics and insurance provider’s information accurate? |
| Are urgent care codes proper? |
| Is documentation clear and comprehensive? |
| Have you ensured compliance with HIPAA? |
| Is the billing process efficient and on time? |
| Is the claim coded and documented accurately? |
| Is the claim submitted to the insurance company within the provided time? |
| Are billed charges matching with contracted rates? |
| Are denied claims managed effectively and timely? |
| Are internal controls effective? |
To align the goals, expectations, and roles to diminish confusion, delays, and conflicts and boost
confidence, satisfaction, and trust, collaboration and communication with patients, staff, and
healthcare providers play a huge role because the lack of collaboration among departments leads to
unproductive billing. Communication with patients is vital in providing clear expectations regarding the
financing process and patient financial responsibility in the case of non-covered services.
Communication, majorly internal communication, reduces confusion, impacts shared beliefs, shapes
attitudes, and helps in implementing knowledge to enhance efficiency and accuracy.
For this purpose, healthcare practitioners can use phone calls, texts, emails, chatbots, surveys,
face-to-face meetings, and webinars, which can be the best approaches. Furthermore, using a consumer
engagement framework may also help build communication channels. For more success, it is suggested to
ask end users about their communication preferences and consider accessible communication channels.
Moreover, offering patient portals for payment can add delight to the dish.
Do’s and don’ts of billing communication
| Do’s | Don’ts |
| Active listening | Assume about patients/clients |
| Concise and clear messaging | Defensive and blaming |
| Response on time | Ignoring their concerns |
| Honesty and transparency | Overpromise and give false hopes |
KPIs are quantitative indicators that provide a yardstick to measure healthcare systems' efficiency,
strategy, productivity, and revenue over time, hence pointing out the pinpoints necessitating management
intervention.
Common urgent care key performance indicators:
Journal of Urgent Care Medicine (JUCM) states some key performance metrics below.
Champions are those practitioners who are committed to staying compliant, implementing changes and are
enthusiastic about convincing administrative and billing staff of the necessity to stay upgraded and
compliant.
Compliance with CMS rules: The Centers for Medicare and Medicaid Services set detailed
rules and regulations such as medical necessity guidelines, complete documentation, and coding accuracy.
Compliance with Federal and state laws: These laws aim to ensure ethical practices and
detect and reduce frauds, protect patients' records, and cover all entities, such as healthcare
providers, insurance companies, and everyone involved in billing and coding.
Compliance with HIPAA rules: Staying compliant with HIPAA guidelines indicates the
safety of HER and, hence, prevention of breach, escaping loss of revenue, and civil and criminal
penalties.
Compliance with private insurance companies’ rules: Insurers often update their
regulations and demands, and deviation from these guidelines can be considered fraud, might impose
fines, or result in claim denials; therefore, adhering to updated rules of insurance companies is
mandatory for a smooth billing process.
Many practitioners offer standard payment plans that are not always effective; therefore, try to give flexible payment options such as dividing the payment into 2 or 3 parts or giving a discount. Regarding payment strategies, it is not recommended to rely on only one method; instead, offer multiple means to pay bills, such as credit cards, which are most commonly used in the USA. Other means are debit cards, portals, cheques, online payments, etc.
As a healthcare provider, you have an integral role in staff training, establishing priorities, and
encouraging and supporting them. For your financial operations to flow smoothly, your staff must be
updated on the latest coding guidelines (codes deleted, revised, or added), latest billing regulations,
software updates, and payers' guidelines.
Follow the tips below for training your billing crew.
Continue training throughout their tenure because investing in staff development will provide positive outcomes regarding employee retention and proficiency, boosted staff morale, job competency, patient satisfaction, and profitability.
Reimbursement programs are implemented to manage care through financial incentives, and value-based reimbursement programs are employed to align professional values with financial incentives in a better way. Nevertheless, poorly designed reimbursement programs often lower the legitimacy of financial incentives. Therefore, integrating value-based reimbursement programs (VBRP) and value-based payment (VBP) models aids in generating value by enhancing quality and cost control; hence, focus on quality billing that aligns with value-based reimbursement for smooth billing, reduced denials, and augmented revenue.
In the era of quality prioritizes quantity, it is challenging to provide quality treatment and focus on
the billing and coding process simultaneously. With more patients, urgent care providers are more likely
to compromise either billing accuracy or treatment quality; therefore, most providers find it a wiser
option to handle their non-core functions with an experienced billing company.
In this regard, MedsIT Nexus offers extraordinary services for your urgent care
facility to
streamline your billing process using various tactics, professionalism, and experience.
MedsIT Nexus is among the top 10 experienced urgent care billing companies all across the USA. Shaking hands with us means you will use updated and cutting-edge technology to manage the billing process efficiently. We also put our decade of expertise into discovering the bottlenecks of your financial operations to decrease AR days and increase revenue. Our coders and billers double-check every step of billing, form auditing regularly, and provide you reports daily, weekly, and monthly. Immediately contact us and provide value-based services to your patients and your billing section.
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