Heather Rothermel
When considering contracting for your clinic, it will be important to know how you plan to market your clinic and to ensure that you align with the needs of your community. Will you be a primary care practice, an urgent care practice, or a blended practice?
Thoroughly analyzing your market and competition should help guide this decision, but there is a bevy of things to consider—everything from contract type, credentialing requirements, reimbursement methodologies, participation criteria, and the impact to members of the health plans you contract with.
Below is a list of requirements and contract language that you could expect to find within each type of agreement.
Primary Care
- Lower co-payment typically applies for members
- Members may be assigned to your practice, and you may be required to accept a certain amount of membership
- Individual provider credentialing is almost always required—providers will not be reimbursed for services rendered until the plan approves the provider’s credentialing in their network
- Payers will typically accept the following provider types at a primary care clinic: general practitioners, family practitioner, internal medicine, pediatrician
- Emergency medicine providers have difficulty obtaining primary-care-provider contracts and getting credentialed
- Reimbursement is typically paid as fee for service and may be lower than urgent care reimbursement
- Providers are typically listed in provider directories individually and marketed individually—not as the facility, which can make your practice hard to find for members
- Some payers may discourage using “urgent care” in the name of your practice
Urgent Care
- Higher co-payment typically applies for members
- Facility credentialing may be required, meaning that all providers would be considered participating as of the contract’s effective date
- Reimbursement is typically a flat or global rate, meaning one negotiated rate is paid regardless of the acuity of care provided during the visit
- The facility itself will be listed in the provider directory, making it easier for members to identify your clinic as participating
- Specific hours of operation may be required, and some payers may be very specific about weekday evening hours (after 5PM) and weekend hours
- May require special accreditation (ie, Urgent Care Association), which costs additional money and may require a site visit
- Generally, the agreement will exclude primary care visits and services (ie, vaccinations, well care, maintenance, etc.)
- May require provider to forward information to patient’s PCP for follow-up care
Hybrid Practice
If you want to run a hybrid practice that includes both primary care and urgent care services, there are 2 options to consider.
The first would be to contract as a primary care or a group practice. In this scenario, you would want to make sure there is reimbursement for any after-hours services that you render (including weekends, evenings, and/or holidays). Individual provider credentialing will be required, and all providers must be approved by the plan prior to being reimbursed as an in-network provider. In this scenario, fee-for-service reimbursement is likely, and it will be important for you to collect the applicable fee schedule to understand your reimbursement.
The other option to consider is contracting as both a primary care and an urgent care. This would require 2 tax identification numbers and contracting for each entity would be separate. In this scenario, you will want a clear understanding of the contracting and credentialing requirements for each entity. There will likely be 2 different reimbursement methodologies to keep track of: 1 for your urgent care; and 1 for your primary care.
After considering all of these variables, you will want to make a decision on how to move forward. Be sure to include your plan for future growth as well. The million-dollar question to ask yourself is what path you will head toward.
Download the article PDF: Contracting: Primary Care Versus Urgent Care
