Journal of Urgent Care Medicine

What To Know About Payers’ Downcoding Procedures

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 …

Mitigating Coding Compliance Risks of AI Documentation Tools

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 …

Benefits of Adding Primary Care Services to Your Urgent Care

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 …

Billing Integrity in Urgent Care: How to Manage Risk

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 …

Mastering Revenue Cycle Management

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 …

ICD-10 Changes Impacting Urgent Care in 2025

Tricia Krueger, CPC, is RCM Coding Supervisor for Experity. ICD-10 has been ever changing since it was first adopted 10 years ago. Each year, the Centers for Medicare & Medicaid Services (CMS) revise, add, and delete diagnoses to better suit the conditions, including the conditions that present in urgent care centers. These changes reflect advances in clinical understanding and the need for more precise documentation in fast-paced care settings. While ICD-10 changes can happen semi-annually, …

Timely Filing: What Every Practice Needs to Know

Nikki Benedict Timely filing is a critical concept in medical billing that directly impacts claim reimbursement. Despite its importance, the specific requirements and terminology can vary across payer contracts, making it essential for billing teams to understand both the general rules and the payer-specific nuances. When reviewing a payer contract, timely filing requirements may be outlined under the following sections: Providers can find Medicare and Medicaid timely filing requirements by consulting Centers for Medicare & …

Credentialing: The Gatekeeper of Access and Reimbursement

Phyllis Dobberstein, CPC, CPMA, CPCO, CEMC, CCC In the healthcare ecosystem, credentialing is more than a bureaucratic hurdle—it’s the linchpin of successful revenue cycle management. For urgent care centers, credentialing determines whether providers can be reimbursed for the care they deliver to insured patients and whether they can participate in insurer networks. Credentialing is the formal process by which payers—commercial insurance companies, Medicare, and Medicaid—verify the qualifications, training, licensure, and work history of care providers. …

Navigating Payer Reviews and Medical Decision-Making: A Critical Guide for Urgent Care

Phyllis Dobberstein, CPC, CPMA, CPCO, CEMC, CCC Urgent care operators face increasing challenges from payer reviews—a situation exacerbated by ongoing confusion around coding guidelines and proper documentation of medical decision-making (MDM). As more urgent care providers grapple with administrative burdens and financial pressures, understanding how to document and code accurately has never been more important. The Rise of Payer Reviews Pre-payment reviews have become commonplace, initiated when a provider’s billing patterns—such as a higher frequency …

Effective Strategies Minimize Claim Denials in Urgent Care

Urgent care centers serve a crucial function in providing prompt and accessible healthcare, but they encounter unique challenges in managing their revenue cycle, particularly in reducing claim denials. Unlike primary care or specialized medical practices, urgent care clinics often treat patients on a one-time basis, making both patient intake and billing more complex. Additionally, frequent turnover among front desk staff contributes to recurring errors in patient registration, insurance verification, and claims processing, all of which …

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