For urgent care centers, uncollected revenue is a critical challenge that directly impacts financial health. This isn’t just about rejected or denied claims; it’s also about failing to actively pursue outstanding payments. Inaccurate claims and neglected follow-ups are not merely lost income—they represent significant additional costs to your practice.
Industry experts emphasize the escalating expenses associated with claim errors. Josh Rainey, VP of Client Success at Experity, points out that reworking a rejected or denied claim can cost five times more than processing a clean claim initially. Adding to this, MGMA data indicates that the average claim rework costs around $25 due to the increased risk of bad debt arising from initial claim failures.
Protecting and maximizing your revenue stream requires a comprehensive approach, integrating medical billing best practices throughout your clinic operations. This includes optimizing front desk procedures, refining payer and coding practices, leveraging insightful reporting, and identifying opportunities for improvement across all clinical and administrative functions.
Optimizing Front Desk Processes for Billing Accuracy
Often perceived as entry-level positions, front desk staff play a pivotal role in the revenue cycle of an urgent care clinic. Despite typically having higher turnover rates, their function in collecting accurate patient information at the initial point of contact is paramount. Errors at this stage can cascade through the entire billing process, leading to significant complications and revenue loss.
In fact, registration and eligibility errors are consistently identified as the primary drivers of billing exceptions. Addressing these front-end issues is crucial for minimizing claim rejections and denials.
Learn how First Care clinics achieved industry-leading performance with only 2% eligibility rejections even during challenging times >>
1. Implement Electronic Patient Registration for Enhanced Data Capture
In today’s digital age, a robust patient engagement (PE) tool is no longer optional but essential for a thriving urgent care clinic. As patients increasingly expect and utilize technology for healthcare interactions, offering electronic registration—whether for reserving a spot, walk-in appointments, or digital check-in—streamlines operations and enhances data accuracy. By prompting patients to pre-register online, they can directly input their information and upload insurance card images. When your PE system is integrated with your Practice Management (PM) system, pre-registration significantly reduces errors, minimizes claim denials, and accelerates the entire pre-visit process for your staff.
2. Real-Time Insurance Verification (RTE/RTV) is Non-Negotiable
A PM system specifically designed for urgent care should include Real-Time Eligibility (RTE) or Real-Time Verification (RTV) capabilities. This allows for immediate insurance verification before the patient encounter. Best practice dictates verifying patient insurance at every applicable visit and, crucially, acting decisively based on the verification outcome. For instance, confirm that Medicaid patients are not covered by a Medicaid CMO or proactively establish payment plans with patients who lack insurance coverage.
If your current PM system lacks RTE/RTV, ensure your front desk staff diligently contacts insurance payers or uses payer portals during, or ideally before, the patient visit to validate insurance coverage.
3. Credit Card on File: Streamlining Patient Payments
Adopting a credit card on file program, ideally through your PM system, is one of the most efficient methods to resolve outstanding patient balances. With patient consent, you can automatically charge their card for the remaining balance after insurance processing. This offers convenience for patients and significantly reduces the likelihood of unpaid balances.
4. Train Staff to Confidently Discuss and Collect Payments
Comfort in discussing financial obligations varies among individuals. Identify staff members who are at ease with payment discussions and equip them with effective scripts to facilitate these conversations. Examples include:
“I see your copay is $25. Would you like to use a card today?” or “I notice a $10 balance from your last visit. May I include that with today’s payment?”
Collecting payments while patients are on-site is significantly more effective than post-visit collections. Prioritize upfront payment collection to minimize patient responsibility accounts going to collections.
5. Diligent Follow-Up on Denied Claims and Unpaid Balances
Whether handled by front desk or dedicated billing staff, consistent follow-up is vital. After claim adjudication and payment posting, accurate reconciliation is key to minimizing bad debt. While the goal is always to submit clean claims initially, many clinics inadvertently write off potentially recoverable charges that could be appealed or corrected and resubmitted. If a payer can remit payment with minor adjustments, the effort to correct and resubmit is a worthwhile investment in revenue recovery.
For balances not collected during the visit, a robust post-visit collection process is essential. Text balance reminders via your PM system offer a quick, simple, and cost-effective solution. These automated texts can include direct links for online payment or the clinic’s billing contact number. Delaying paper statements until after multiple text reminders fail can also significantly reduce paper billing costs. If text reminders aren’t available, establish a routine for staff to follow up with phone calls on aging accounts receivable.
Numerous additional steps within the check-in and check-out process can further enhance revenue recovery. This blog provides a valuable front desk checklist PDF with more tips to optimize front desk operations for billing efficiency.
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Coding, Credentialing, and Insurance Practices: Key to Clean Claims
Providers, owners, and managers also play a critical role in minimizing claim rejections and denials. Oversights in coding accuracy and staying updated with industry changes are common sources of billing errors. Implementing these best practices will help avoid costly mistakes and improve revenue cycles.
1. Secure Robust Payer Contracts
Inadequate or non-existent payer contracts directly and negatively impact your clinic’s reimbursement rates. Correct payer contracts are foundational for accurate and timely claim processing and payments.
Establishing contracts with major payers in your service area is essential, ideally before launching your urgent care. Delaying contract negotiations can restrict your ability to accept insurance, potentially limiting patient volume to cash-pay only until contracts are in place.
Expert Advice: Engage a professional contracting expert specializing in your region’s payers. They can effectively negotiate on your behalf, navigate complex contract details, and secure optimal reimbursement rates, especially beneficial for new urgent care centers.
2. Stay Updated on Coding Changes and Ensure Code Accuracy
Providers often develop comfort zones with Evaluation and Management (E/M) code selection. There can be a tendency to default to Level 2 or 3 codes as a perceived “safe” choice, even when documentation supports higher-level coding. Consistently undercoding can result in significant daily revenue losses.
The American Medical Association releases annual updates to CPT codes. If your coding team is not current with these changes and lacks ongoing training and recertification, claims submitted with outdated codes will lead to denials and lost revenue.
An EMR system tailored for urgent care can significantly improve coding accuracy by providing built-in coding recommendations based on common episodic visits. Furthermore, regularly reviewing Urgent Care Coding Reports generated by your EMR can identify trends in coding practices and areas for improvement.
3. Master the Use of Code Modifiers
Services frequently don’t perfectly align with single CPT codes. Modifiers are crucial for accurately detailing the services provided. For instance, when a patient undergoes multiple distinct procedures during the same visit, modifiers clarify these nuances. Misuse, incorrect application, or omission of modifiers are common errors. Understanding payer-specific guidelines is also vital, as acceptance of certain modifiers varies. Incorrect modifier usage is a frequent cause of claim denials.
Understanding HCPCS Level codes is also critical for appropriate reimbursement. HCPCS Level I codes are CPT codes for procedures and services. HCPCS Level II codes cover injectable drugs, durable medical equipment, and supplies provided in addition to treatment, such as splints or crutches. When dispensing medical equipment, ensure accurate use of code modifiers to prevent claim denials. Regular audits of coding reports, specifically focusing on modifier usage, can highlight areas needing attention.
4. Regularly Verify Clinician Credentialing
Maintaining up-to-date provider credentialing is essential for claim reimbursement. Alongside credentialing, accurate system configuration within your billing and PM systems is equally important. Quarterly credentialing verification is recommended to proactively identify and rectify any lapses that could disrupt payments.
Need guidance on billing for non-credentialed or non-contracted providers? Explore this resource >>
Leveraging Reports, Metrics, and Audits for Financial Oversight
Auditing, comprehensive reporting, and Key Performance Indicators (KPIs) are fundamental to your urgent care’s financial success and optimized medical billing practices. Key metrics for urgent care success have been detailed in various resources, including a simplified explanation and calculation guide available here. In addition to monitoring these KPIs, consider these best practices for a healthy Revenue Cycle Management (RCM). Crucially, urgent care coding reports are central to this process, providing the granular data needed for effective analysis and improvement.
1. Monitor Critical Monthly Metrics
Essential monthly metrics to track include:
- Days Sales Outstanding (DSO): Measures the average number of days to collect payment after a service.
- Days to Bill: Tracks the time lag between service date and claim submission.
- Evaluation and Management (E/M) Weights: The average complexity level of E/M codes billed. Analyzing urgent care coding reports can help understand E/M distribution.
- Average Revenue per Visit: Provides insight into the average income generated per patient visit.
- Percentage of A/R over 120 days: Indicates the proportion of outstanding receivables that are aged beyond 120 days.
Tracking these metrics provides insights into current performance, identifies areas for improvement, and allows you to gauge the effectiveness of implemented changes. Urgent care coding reports can provide the detailed data underpinning many of these metrics.
2. Generate Monthly Financial Performance Reports
Your PM system’s reporting capabilities offer a broader view of your clinic’s overall financial health. Regular month-end reports are essential for identifying trends, changes, opportunities, and successes. Data-driven insights inform better decisions across RCM, staffing levels, operating hours, and budgeting. If extracting necessary data from your current reporting tools is challenging, consider a dedicated business intelligence solution. These advanced tools often offer more sophisticated urgent care coding reports and financial dashboards.
3. Conduct Periodic Denied Claim Audits
Regularly audit denied claims to identify recurring denial patterns. This analysis informs targeted staff training to address common errors and allows for updates to Standard Operating Procedures (SOPs) to prevent future denials. Analyzing urgent care coding reports in conjunction with denial reports can pinpoint coding-related denial trends. Peer coaching opportunities can also emerge by identifying staff with varying performance in specific areas.
4. Benchmark Claim Levels Against Industry Norms
Analyze your practice’s claim levels over several years and compare them against industry benchmarks. This comparison helps identify potential under-coding or up-coding practices relative to peers. If using an EMR, examine if providers frequently override system-suggested codes or consistently select a single code level. Ensure your coders are continuously updated on coding changes. Urgent care coding reports that detail code distribution by provider can be invaluable in this analysis.
If you are seeking an EMR/PM system with features like urgent care coding recommendations, insurance verification, text balance reminders, credit card on file, and robust reporting – including comprehensive urgent care coding reports – Experity could be an ideal solution. Explore the full range of benefits on their product page.
Explore Experity’s Urgent Care Software Suite
Additional Medical Billing Best Practices for Revenue Protection
Several other recommendations can further minimize revenue leakage in your medical billing process.
1. Ensure Comprehensive Documentation for All Billable Services
Incomplete documentation leads to missed charges. Common omissions include labs, blood draws, injection administrations, x-rays, and interpretation of results.
Providers may also neglect to document units of service or drug dosage amounts. Accurate quantities of dispensed drugs are crucial for correct claim charges. Insufficient procedural documentation delays claim submission and results in lost reimbursement.
Train providers to consistently document frequently missed charges like labs and injections. Maintain an easily accessible list and drug dosage conversion table. Log all requested labs and dispensed drugs and cross-reference these against claim charges. Regular review of urgent care coding reports can also help identify patterns of under-documented or under-coded services.
2. Update or Create Standard Operating Procedures (SOPs)
These best practices should be formalized into SOPs to guide and train staff, ensuring consistency and clarity in their roles and responsibilities. Regularly train current staff on any new processes or updates to existing procedures aimed at improving billing accuracy and efficiency.
3. Leverage the Right Technology
Throughout this discussion, various technology features have been highlighted as crucial for streamlined and accurate billing. Outdated technology can hinder efficiency, increase error rates, and negatively impact patient experience. Key technology solutions include:
- Pre-registration: Integrated PE and PM systems enable online patient registration, reducing clerical errors and wait times.
- RTE/RTV: Immediate insurance verification within your PM system allows for upfront copay collection and payment plan arrangements.
- Credit Card on File: Securely storing credit card information within your PM facilitates automatic balance payments, minimizing collections.
- Text Balance Reminders: Automated payment notifications via text from your PM system simplify bill payment for both clinic and patient.
- Coding Recommendations: EMR systems like Experity offer coding suggestions based on current regulations, ensuring claim accuracy and faster reimbursement. Furthermore, robust urgent care coding reports within these systems provide valuable insights into coding practices.
Experity’s integrated solutions offer these features and more. Learn more about their comprehensive offerings here >>
4. Consider Outsourcing Revenue Cycle Management
When seeking to improve RCM, a key consideration is whether to manage improvements in-house or outsource to specialized experts. This is a relevant question for urgent cares of all sizes. If you lack the time or in-house expertise to manage the complexities of billing—including error detection, A/R follow-up, payer contracting, and claim resubmission—outsourcing may be the most efficient and cost-effective solution. Review a detailed comparison of in-house versus outsourced billing in this eBook >>
Additionally, explore Experity’s RCM services here >>
Identify Your Revenue Cycle Weak Points with a Free Billing Analysis
Optimizing your medical billing processes can feel overwhelming. Determining where to begin or pinpointing areas needing most improvement can be challenging. While outsourcing billing is a significant decision, Experity offers a valuable middle ground: a free billing analysis. This analysis pinpoints areas where you can achieve the most impactful RCM improvements without immediate outsourcing commitments.
While many urgent care owners are confident in their claim submission and cash posting efficiency (representing only 30-40% of the revenue cycle), Experity RCM experts have consistently found significant improvement opportunities within the remaining 60-70% through over 400 billing audits. Clinics often unknowingly make similar mistakes, revealing substantial potential for revenue optimization. This free billing analysis carries no obligation to commit to Experity RCM services. If you are looking for expert insights, sign up today.
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