Journal of Urgent Care Medicine

Accurate AI Coding Boosted Reimbursement Among Highmark Providers

Highmark Health is finding that artificial intelligence (AI) can influence reimbursement, according to Modern Healthcare. The integrated system’s insurance unit posted an operating loss that was tied to higher utilization as well as an increase in coding accuracy coming from providers in their claim submissions. Thanks to AI, providers are more likely to submit cleaner claims that better reflect the reality of clinical care and patient acuity—which also may incur higher reimbursement. It’s not fraud, …

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. …

Health Systems Break Ties With UnitedHealthcare

Several major health systems are struggling to reach contract agreements with UnitedHealthcare (UHC) to provide care services for members covered by the insurer. Recently, Duke Health posted in a blog that its UHC reimbursement is below the 25th percentile among similar hospitals in North Carolina, which it calls “unacceptable” as it continues contracting talks with UHC. If no agreement is achieved, Duke will be out-of-network as of November 1 for several health plan products, including …

Developing a Reimbursement Policy for CME and Other Employee Expenses

Urgent message: Every urgent care center should have a clear policy outlining which employee expenses, including CME-related expenses, it reimburses and how reimbursement occurs. Alan A. Ayers, MBA, MAcc is Chief Executive Officer of Velocity Urgent Care and is Practice Management Editor of The Journal of Urgent Care Medicine. Managers, owners, and supervisors in nearly every field need to be familiar with the process of reimbursing employees for costs incurred while doing company business. Whether …

Independence Blue Cross Slashes Reimbursements on Modifier 25

Independence Blue Cross has implemented a new policy that cuts reimbursements on procedures billed with modifier 25 (“Significant, separately identifiable E/M service”) by half for care given to Medicare Advantage members and patients covered by private insurance plans. The lower rate does not apply to traditional Medicare claims. Independence covers patients under its own name, but also through QCC Insurance Company, Keystone Health Plan Eastand AmeriHealth. The move sets Independence apart from other payers, including …

Maximizing Reimbursement for Services on Campus, off Campus, or on the Phone

Q: We are coding for an urgent care group that is owned by a hospital and bills on a CMS-1500 for professional services and the UB-04 for facility services. We bill using Place of Service (POS) code 22. Is this correct? A: Prior to January 1, 2016, the Centers for Medicare and Medicaid Services (CMS) POS code set did not differentiate between an urgent care operating on campus or off campus. As of January 1, …

Understanding the Impacts of Health-Care Reform on Urgent Care

Urgent message: Urgent care plays a vital role in reducing medical expenses and improving population health by enabling the right care, at the right place, by the right provider, at the right price. Introduction Health-care reform, quality of care, and costs are center stage topics for politicians and the general public. As medical providers and administrators in the United States, we share in the challenge of understanding this complex system. Whereas traditional approaches in the …

Prosecutors Vigilant to Questionable Medicare Bonuses

A settlement with a billing company in Massachusetts is just the latest outcome of federal prosecutors going after healthcare companies for return of Medicare bonuses claimed in error. It’s a reminder that filing for claims improperly—even if inadvertently—can have serious consequences for operators. In this case, Medical Reimbursement Systems Inc. has agreed to pay $500,000 to settle allegations that it submitted false claims to the military’s Tricare program on behalf of a medical practice in …

Developing Data: October, 2013

These data from the 2012 Urgent Care Industry Benchmarking Study are based on a sample of 1,732 urgent care centers; 95.2% of the respondents were UCA members. Among other criteria, the study was limited to centers that have a licensed provider onsite at all times; have two or more exam rooms; typically are open 7 days/week, 4 hours/day, at least 3,000 hours/year; and treat patients of all ages (unless specifically a pediatric urgent care). In …

Login to JUCM