Revenue Cycle Management

Tricia Krueger, CPC; Nikki Benedict Insurers are drawing provider backlash for new payment policies that reduce reimbursements. For example, Cigna is automatically “downcoding” 6 evaluation and management (E/M) billing codes for a small percentage of providers, resulting in lower payments for routine services like office visits. Aetna’s new Medicare Advantage policy will automatically approve certain hospital admissions but reimburse them at the lower observation rate instead of the full inpatient rate. Providers argue these opaque methods increase administrative costs and lead to underpayment. Implications for Urgent Care Centers The new …
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Three types of artificial intelligence (AI) technologies are quickly moving to the urgent care exam room: real-time transcription; real-time coding; and clinical decision support systems.[1] They promise to reduce clinician burden per visit, improve documentation in the medical record, reduce cost per episode of care, and improve reimbursement. They may create challenges related to clinical ownership, medical decision making, and compliance, however.[2] Notes and code suggestions generated by AI for urgent care patients are likely to increase, but the clinician’s documentation will remain closely tied to their clinical reasoning and …
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Phyllis Dobberstein, CPC, CPMA, CPCO, CEMC, CCC In the last few years, the Centers for Medicare & Medicaid Services (CMS) has accelerated its long-term effort to strengthen primary care as the foundation of the U.S. health system. Through new payment models, regulatory changes, and equity-driven initiatives, CMS aims to rebalance healthcare spending toward prevention, care coordination, and whole-person health. All these are areas historically underfunded compared to specialty or hospital care. Major policy changes have been enacted through the Physician Fee Schedule (PFS), including increased payment for longitudinal and continuous …
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Phyllis Dobberstein, CPC, CPMA, CPCO, CEMC, CCC, is Revenue Integrity Manager at Experity. The financial and reputational health of an urgent care practice depends on one simple principle: Bill accurately and compliantly. Yet as reimbursement rules evolve and staffing models shift toward greater reliance on non-physician practitioners (NPPs), many centers find themselves at risk for costly missteps. From billing under the wrong provider to out-of-network (OON) complications and False Claims Act (FCA) violations, administrators are navigating an increasingly complex compliance landscape. Understanding how these issues intersect—and building proactive strategies to …
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Phyllis Dobberstein, CPC, CPMA, CPCO, CEMC, CCC Revenue cycle management (RCM) may not be the most glamorous part of urgent care, but it is one of the most critical. A clinic can provide excellent patient care, yet still struggle to keep its doors open if its billing processes falter. Too often, urgent care leaders rely on assumptions, outdated practices, or incomplete data that lead to financial surprises and lost revenue. Running an effective Revenue Cycle Management program is like taking a photograph. When a camera is set to automatic mode, …
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