URGENT MESSAGE: As payers introduce new clauses into urgent care-specific contracts, urgent care operators need to be vigilant to how several changes may affect their day-to-day operations.
With each new clause, provider contracts offered by payers become more complex, adding a host of burdens to the day-to-day operations of the urgent care center—eg, staff and documentation required for credentialing, ongoing training on fraud and abuse, and restrictions on the ability to “off-shore” billing and other services. There are several changes, in particular, that urgent care center operators need to understand and comply with in order to ensure those contracts are equitable.
In-house credentialing verification: For many years, insurance companies assumed that urgent care centers were performing primary source verifications on the professional credentials of their providers, only to find that is not happening. According to many insurance contracts, the urgent care center is required to perform in-house verification of each provider’s credentials and keep documentation on file. If you have any ancillary or facility contracts that do not require you to submit individual provider credentialing paperwork to the payer, you may be required to perform credentialing in-house.
This means you need to designate a staff member’s time and resources to make sure the tasks are getting done. If the insurance company decides to audit the center and finds that the provider credentialing verification has not been documented, the urgent care facility would be subject to consequences—possibly leading to contract termination.
One large urgent care chain uses the following verification process:
- Collection of provider documents (eg, credentials, certificates, licenses, malpractice claims). Employment offer pending successful verification of credentials and credentials committee approval.
- Verification of credentials (not all inclusive):
- Medical license
- Past employment
- National Practitioner Data Bank (NPDB)
- Office of Inspector General (OIG)
- Credentials committee (odd number for voting purposes) reviews verified credentials of practitioners to assess quality and determine if an employment offer will be made.
- Verifications are kept confidential with other human resources files.
- Credentials are then reverified every 2 years thereafter.
Offshore billing or other vendor services: Thinking about using an offshore billing company to save money? You might want to reconsider. Providers are prohibited from using services performed by vendors who are not U.S.-based or who use subcontractors outside the U.S. (without prior written approval from the payer) under one new clause payers are adding. An urgent care center could be ineligible for payment under such payer contracts if they use software, billing, medical transcription services, radiology readings, clinical decision support, etc. from vendors who locate any portion of their operation outside the U.S. (or even use offshore subcontractors). These facilities could also be subject to take-back of payments received while using the offshore-linked vendor. And the urgent care center could lose its payer contract if found in violation of the clause.
To avoid serious complications, ask vendors about offshore connections before signing a contract or renewal agreement. From a quality and security standpoint, it is best to stick with U.S.-based vendors.
Fraud, waste, and abuse training: There’s a new requirement for providers to complete this compliance training developed by CMS. Aetna is the first payer to include it in most contracts, but other payers are following suit. Providers must complete the web-based training program within 90 days of hire and repeat the program annually. Upon passing a test at the end of training with a score of 70% or higher providers get a certificate of completion. The urgent care center is expected to keep a signed copy on file for 10 years. If the urgent care center is audited and found to be non-compliant, the payer could pull the contract.
The training is designed to help providers detect, correct, and prevent fraud, waste, and abuse that results in millions of misspent dollars every year by detailing relevant laws, reporting methods, and related consequences, according to CMS. Trainees are taken through various scenarios during the training, which takes about 2 hours to complete, to test their knowledge of the lessons.
In conclusion, urgent care operators need to be aware of emerging contract clauses and changes to avoid costly and frustrating delays. Don’t risk having one of your payer contracts severed because of a new rule you’re not tuned into. Partnering with a contracting and credentialing specialist can help ensure your compliance and long-term success.