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Medically necessary is hard to define to universal approval, with insurers and healthcare professionals often being on opposite sides. Some shady service providers are looking for ways to exploit that divide for their own profit, sometimes leaving urgent care operators at risk for penalties, potentially. Right now, some allergy companies “offer” to help practices initiate allergy testing and immunotherapy services; the company places an employee on site to handle the allergy tests and facilitate immunotherapy—in other words, the operator is enticed by the prospect of being able to offer a new service to patients without having to hire (and pay) a new employee, all the while collecting more fees. Even better, at least on paper, the company doesn’t take any money up front; when the services are billed by the practice under the physicians’ National Provider Identifier numbers, the vendor gets a cut. The problem for the urgent care provider is that Blue Cross does not cover services unless they are medically necessary and covered by the member’s chosen benefits. The whole concept promotes administering tests and treatments that may not be “medically necessary” in any responsible provider’s mind. As with telemarketing schemes that look to get money from consumers, be wary of companies that claim to provide products or services that would be good for your patients, but focus their message on helping you raise revenues—a healthy percentage of which would be their only payment. Stick with vendors you know and trust, and be aware of all payers’ positions on what’s deemed necessary. The consequences if you don’t could be severe; one major urgent care company was forced to pay a $10 million penalty for encouraging its providers to offer allergy tests, and other services, to patients for whom the tests were not indicated.

Watch Out for Shady Allergy Testing—and Billing—Schemes
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