Major changes are afoot for urgent care centers that treat patients under Medicaid and the Children’s Health Insurance Program (CHIP), thanks to a new rule the Centers for Medicare and Medicaid Services (CMS) is imposing. In addition to new requirements for insurers, the rule also creates new compliance and administrative burdens that could affect revenue for medical practices (eg, requiring care coordination between different settings and institution of quality-rating systems and allowing states to encourage plans to develop contracts that demand performance improvement and delivery reform). DecisionHealth’s offers a few tips on how practices can prepare to thrive under the new rule:

  • Study what insurers do in response and do a cost-benefit analysis. If you’re not in a network, investigate keep an eye on how plans will handle out-of-network reimbursement.
  • Read the fine print in new contracts and amendments, especially as they relate to new quality reporting and performance requirements or repaying overpayments.
  • Ensure that your reimbursements are adequate. The new CMS rule is phasing out state-sanctioned pass-through payments that some providers rely on to supplement the contracted reimbursement.
  • When you get the new/revised provider manual from a plan, read it! It’s likely some plans will roll out changes by updating their manuals first (not just when revising contracts).
  • Be part of the discussion in your state; stay vigilant for “public comments” notices.
  • Understand the rules in neighboring states, not just your own. Patients often cross state lines for treatment, and the rules will not be the same.
Is Urgent Care Prepared for Medicaid and CHIP Overhaul?
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