Urgent message: Conducting immigration physicals can be surprisingly lucrative. These relatively high-priced, cash-only visits incur no insurance billing or accounts receivable carrying costs. And because they are scheduled, ebbs and flows in patient volume can be leveled. Here’s how it works.
Alan A. Ayers, MBA, MAcc Practice Velocity
The success of a new urgent care center in a community requires a change in consumer behavior, with a sufficient number of residents shifting their utilization from emergency departments and primary care physicians.
As such, building sufficient volume to reach breakeven can take a couple of years. But even after volume has stabilized, many urgent care operators find it difficult to grow profits year after year, particularly when faced with rising operating costs and cuts to Medicare and private insurance reimbursement. Once revenue is sufficient to cover such operating costs as salaries, rent, utilities, advertising, and depreciation, each incremental visit contributes directly to the bottom line.
To increase volume and enhance the profitability, many urgent care operators turn to ancillary services. These are generally cash-only services that leverage existing clinic infrastructure but do not entail treating minor injury and illness. The primary advantage of ancillary services is that accepting only cash means no billing or accounts-receivable carrying costs. In addition, ancillary services can be scheduled, flattening the ebb and flow in walk-in volume. Moreover, they can help raise public awareness of a center’s services and attract new urgent care patients.
A common ancillary service for urgent care providers is “immigration medicine”: documentation of physical exams, vaccinations, and lab tests required by the United States Citizen and Immigration Services (USCIS) for every non-US citizen desiring a change in his/her residency or citizenship status. Immigration physicals require that a physician hold a “civil surgeon” designation, understand the paperwork and examination requirements involved, carry a limited inventory of vaccines, and have access to a clinical reference laboratory.
Civil Surgeon Designation
To practice immigration medicine, a physician first must earn a civil surgeon designation. According to the USCIS website (www.uscis.gov), this entails locating the USCIS District Office serving the provider’s state (a locator by zip code is available on the website) and submitting the following documents:
- A letter to the District Director requesting consideration
- A copy of the provider’s current medical license
- A current CV that shows four years of professional experience (excluding residency)
- Proof of US citizenship or lawful status in the US
- Two signature cards with the provider’s name typed or printed as well as signed
No separate form or application is required. However, there are only a limited number of designated civil surgeons appointed to each geographic area; new applicants will be turned away or waitlisted if there is already a sufficient number in their community. Once designated as a civil surgeon, a provider will be listed on the USCIS website and may begin offering immigration physicals to the general public.
Paperwork and Examination
The purpose of immigration physicals is to assure that individuals seeking citizenship or permanent residency in the US do not have physical or mental conditions that pose a threat to the health, safety, and welfare of the nation or lead to exclusion under immigration laws. Although the actual physical exam is not particularly time-consuming for the civil surgeon to conduct, considerable paperwork is involved for front office staff. Flow sheets and checklists can be created to facilitate these transactions and assure that staffers complete the necessary documentation properly (Table 1).
- Patient Information Form
- Demographics and basic health information
- Applicable medical records
- USCIS Form I-693: Report of Medical Examination and Vaccination Record
- Patients should complete the demographics section in ad- vance of the appointment
- Clinics providing immigration physicals should also keep copies of the forms on-site
- Vaccination records (Table 2), showing proof of vaccination, which includes:
- Type of vaccination administered
- Date administered
- Physician who administered the vaccination
- Copies of previous test results, if applicable:
- Tuberculosis skin test or chest x-ray
- Photo identification
Once the front-desk staff reviews all materials, they determine which immunizations and tests have been administered and which are needed. When vaccination records are in a foreign language, the patient should provide a certified English translation; otherwise, the record cannot be relied upon and it must be assumed that vaccinations have not been administered. Current USCIS vaccination requirements include:
- Tetanus and diphtheria toxoids
- Haemophilus influenzae type B
- Hepatitis B
- Any other vaccine-preventable diseases recommended by the Advisory Committee for Immunization Practices
Necessary vaccinations are administered by the clinic staff or a waiver is sought according to USCIS guidelines, which may be based on age, medical appropriateness, or religious convictions. After the vaccination record is completed, the civil surgeon conducts the physical examination.
Form I-693 specifies examination components, which differ depending on the age of the patient and will include, at minimum, examination of the eyes, ears, nose, throat, extremities, heart, lungs, abdomen, lymph nodes, skin, and external genitalia. The Centers for Disease Control and Prevention provide technical instructions for conducting the physical examination that address issues that could exclude an applicant or require further investigation. Such potentially exclusionary issues include physical and mental conditions, communicable diseases, substance abuse, and criminal behavior.
A laboratory test for syphilis is also required as part of the exam- ination requirements. Blood is drawn and sent out by the clinic staff; once results are received, they are documented by the physician on Form I-693. A downloadable form is available at www.uscis.gov/files/ form/i-693.pdf.
The completed original Form I-693 with the civil surgeon’s signature, a copy of the patient’s photo ID, and a chest x-ray (if applicable) are then sealed in an envelope and given to the patient to submit unopened to the USCIS with his/her application for processing.
Immigration physicals are a cash-only business. They entail checking vaccination records to assure that an applicant is current on all required vaccinations, conducting tests for syphilis and tuberculosis, and conducting a physical exam by an authorized civil surgeon. Fees come from processing the paperwork, conducting the physical exam, and administering necessary tests and immunizations. USCIS does not have a set or recommended fee schedule for immigration physicals; pricing is up to the individual provider (Table 3). Typically an urgent care center will charge a base fee of $75-$150 for the physical and then charge à la carte for vaccinations, tests, or x-rays administered, resulting in a total visit charge of $250-$300 or more. To simplify pricing, some practices offer an all-inclusive immigration physical for $400-$450 or more, regardless of actual services administered. With moderate volume in a metropolitan area, immigration physicals can easily add $100,000 or more to an urgent care center’s net collections. When establishing rates, keep in mind that families tend to come for immigration physicals together. A married couple with two children could easily generate $800-$1,200 in cash revenue in a single appointment. In addition, applicants with USCIS span the economic spectrum—from engineers with PhDs to day laborers—so price elasticity may be advisable, depending on the applicant profile in a community. To capture new business from patient referrals and generate positive word of mouth in immigrant social circles, pricing must be competitive with rates offered by other immigration medicine providers in the community.
On the other hand, it is important to hold firm on rates once they are set. Members of some non-American cultures are accustomed to bartering and will attempt to “talk down” or engage in other tactics to secure a lower price. When the price is reduced for one sympathetic individual, word may quickly spread that a center’s pricing is negotiable and result in an expectation of discounts for all.
Likewise, paperwork should never be released to a patient without payment in full. The odds of collecting immigration physical fees after the fact are slim to none. When immigration physicals are promoted as a cash- only service, the onus is on patients to seek reimbursement from an employer, insurer, or other third party.
Marketing of Immigration Physicals
Because the duty to obtain an immigration physical falls on the applicant, individuals requiring the service will generally visit the USCIS website or ask a local congress- man’s office, immigration office, friends, family, attorney, or religious leader for advice on where to go. Although urgent care providers are wise to develop relationships with local immigration attorneys, advocacy groups, or places of worship—providing marketing materials for them to display or distribute most referrals come from word of mouth. Some providers see fairly significant immigration physical volume with- out any paid marketing at all.
Certain operational factors, however, may affect how appealing an urgent care facility is to certain immigrant groups. For instance, does the facility offer both male and female civil surgeons? Some cultures prohibit a patient from seeing a provider of the opposite sex. Is the facility open on Sunday? Some religious groups observe Friday or Saturday as Sabbath holy days. Also, Fridays and Saturdays are workdays for many immigrants. Is the center staff bilingual? If not, is a translator avail- able? If there are large immigrant populations in your community, it may be useful to enlist the assistance of ethnic advocacy groups in providing translation services. Is the facility accessible to a bus line? In urban areas, it is common for recent immigrants to lack reliable transportation.
Even when multiple clinics provide immigration physicals in a community, some applicants in major metropolitan areas have been known to drive three hours or longer to another city if a provider is available with male and female practitioners, Sunday hours, fast turn- around time on documentation, and affordable rates.
Because immigration physicals bring new patients to the urgent care center, they provide an opportunity to educate patients who may not be familiar with the US medical system or know when to choose urgent care for a family’s personal injury and illness needs. Many recent immigrants lack access to basic primary care but nevertheless may have episodic health needs that could be served by urgent care.
In addition, immigration physicals may capture referrals for other ancillary services eg, travel medicine especially when parents are inoculated for foreign travel but their US-born children are not. Patients who are satisfied with their immigration physical experience have an incentive to return to the center often and to advise friends and family to do likewise.
Walk-in vs Scheduled Appointments
Although urgent care centers treat illness and injury on a walk-in basis, many centers use scheduled appointments for immigration physicals. The advantage of scheduled appointments is the ability to direct time-consuming physicals to non-peak days and hours. Walk-in clinics typically see declines in visit flow during mid- to late afternoon and mid-week, as well as seasonally during weekend hours. Scheduling physicals in these time slots can result in better utilization of fixed staff and facility investments without adversely affecting overall wait times. If a center lacks a computerized scheduler, a paper appointment book (available at office supply stores) will generally suffice for a single center.
The only limitation is that the times that work best for the center may be inconvenient for applicants. If, for example, a center chooses to perform immigration physicals during peak urgent care times (eg, Saturday mornings), adding additional front office staff and/or providers to avoid extending wait times in the core urgent care business should be considered.
High fixed costs and third-party payer reimbursement in urgent care mean that even after a breakeven volume for patient visits is attained, visits from additional patients can enhance a center’s operating margins. Ancillary services like immigration physicals have been embraced by many urgent care operators as a way to increase profitability through relatively high-priced visits that incur no insurance billing or accounts-receivable carrying costs.
The keys to success are providers who are engaged and willing to seek the civil surgeon designation, keeping the required vaccinations in stock, learning the requirements for conducting an immigration physical exam, and providing a quality patient experience that will at- tract repeat and new business through word-of-mouth referrals.