Contracting: Primary Care Versus Urgent Care

Contracting: Primary Care Versus Urgent Care

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, …

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Why Does Start-Up Contracting Take So Long?

Why Does Start-Up Contracting Take So Long?

Heather Rothermel Consider this scenario: You’ve decided to open an urgent care center. You’ve secured funding, found the perfect location, hired amazing providers, created build-out plans to make it your own, and set a go-live date to open your doors to your community. Then you realize you haven’t started contracting and credentialing. In many markets, contracting and credentialing for a start-up can take 9 to 12 months or longer, and operators must consider this timeline …

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What is a False Claim?

What is a False Claim?

Benjamin Barlow, MD; Phyllis Dobberstein, CPC, CPMA, CPCO, CEMC, CCC The False Claims Act (FCA) is a federal statute enacted in 1863, inspired by defense-contractor fraud during the Civil War. Today it is used to prosecute inappropriate billing in the healthcare setting. Any person who knowingly submits false claims to the government (ie, Medicare, Medicaid, and Tricare) is liable for 3 times the government’s damages plus a penalty that is linked to inflation. Penalties are per …

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Nine Recurring Coding Pitfalls for Urgent Care Clinicians to Avoid

Nine Recurring Coding Pitfalls for Urgent Care Clinicians to Avoid

Brad Laymon, PA, CPC, CEMC Over my career as a physician assistant, I have delved extensively into the intricacies of medical coding guidelines. Through collaborative initiatives with healthcare systems and fellow clinicians, I have been able to identify 9 common, recurring coding pitfalls. This process came with significant time and experience, and I want to share what I’ve learned as my ultimate objective has always been advancing charting accuracy to instill confidence among providers in …

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How to Survive a Payer Review

How to Survive a Payer Review

Benjamin Barlow, MD; Phyllis Dobberstein, CPC, CPMA, CPCO, CEMC, CCC One of the biggest challenges facing urgent care operators is increased scrutiny in the form of payer reviews. More clients than ever are facing these administrative and financial burdens. Compounding the issue is that urgent care clinicians often struggle to understand coding guidelines and how to document in a way that shows their medical decision making, which is vital in care and in payer reviews. Prepayment …

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The Challenges of Billing Out-of-Network

The Challenges of Billing Out-of-Network

Phyllis Dobberstein, CPC, CPMA, CPCO, CEMC, CCC One of the biggest challenges for an urgent care is billing insurance as a non-participating provider. When opening a new practice or adding a clinic, completed credentialing and contracting is essential and has a direct impact on the overall success for a new business. Opening without effective dates may result in cash flow shortages due to the fact that most health plans will not offer retroactive effective dates. Additionally, …

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ICD-10-CM: What’s New for 2024

Phyllis Dobberstein, CPC, CPMA, CPCO, CEMC, CCC, is RCM Compliance Manager, Experity With the fall season comes all the coding changes for the year. This starts with the 2024 edition of the ICD-10-CM codes, which went into effect on October 1, 2023. As a reminder, there is no grace period. Changes are effective on dates of service as of October 1. Prior to this date, practices should continue to use the 2023 ICD-10-CM code set. This …

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Is It Time to Revisit Your Urgent Care Marketing Tactics?

Is It Time to Revisit Your Urgent Care Marketing Tactics?

Heather Real Click Here to download the article PDF In the journey of an urgent care visit, where does the patient story begin? Is it when the patient walks through the door, or did it start when the patient was still at home Googling “urgent care near me” on their phone? It is likely neither of these. The patient journey to your urgent care actually begins before they even have a sniffle, fever, or injury; …

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Modifier 25: What You Need to Know

Modifier 25: What You Need to Know

Phyllis Dobberstein, CPC, CPMA, CPCO, CEMC, CCC Modifier 25 is used to indicate a significant, separately identifiable evaluation and management (E/M) service was required on the day of a minor surgical procedure. The procedure performed must have a global period of 0 or 10 days. An example of this is a laceration repair. Modifier 25 is overused in the industry and has been under scrutiny from payers for decades. Now private payers are implementing policies …

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De Novo vs Acquisition: What’s the Best Pathway for Urgent Care Growth?

De Novo vs Acquisition: What’s the Best Pathway for Urgent Care Growth?

Click Here to download the article PDF Urgent message: When considering growth in urgent care, there are both advantages and challenges to acquiring an existing urgent care center vs developing a completely new business. Heather Real The urgent care industry is ever-evolving and flexing to meet the needs of patients and communities. This means the way operators enter the industry needs to be flexible, too. While starting a new business in a freshly outfitted space …

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