Urgent Care billing and accounts receivable

Urgent care is walk-in evaluation and management at volume, plus laceration repair, splinting, incision and drainage, foreign body removal, in-house X-ray and rapid testing. Patients arrive without appointments, many of them new to the centre, so coverage is captured at the desk under pressure and there is no scheduled window in which to check it before the visit.

Where the money leaks in urgent care

These are the recurring denial reasons in this specialty. They are not exotic. They are the ordinary ones that go unworked because the person who could fix them is at the front desk answering a phone.

• Coverage taken from whatever card the walk-in hands over at the desk and never checked against the plan, so the claim goes to a policy the patient left months ago
• A global urgent care case rate billed alongside a separate evaluation and management line where the contract pays one or the other, and the second line drops off
• Fracture care billed as definitive treatment when the patient was splinted, immobilised and sent on to orthopaedics the same day
• Laceration repair paid at the simplest level because the note says the wound was closed but never records its length, its site or whether the closure was layered
• Work injuries billed to the patient's health plan because nobody asked at registration, with no employer authorization or claim number on file
• The in-house X-ray billed globally by the centre while the teleradiology group bills the professional read on the same film, so one line denies as a duplicate

What a seat does about it

One trained person works your queue from the difficult end. Every call is logged with the payer reference number and the outcome, so an appeal can quote what was said rather than start again. Denials are categorised, which is how the same reason stops coming back next month. On Friday you get it in writing.

The roles that matter most in this specialty are AR calling and denials at $1,700, prior authorization at $1,900, and certified coding at $2,500.

The codes those turn into

Each of these is a denial code you are likely to meet working urgent care, matched to the problem above it in your own words. The route back to payment differs by code, so a queue sorted by recovery route clears faster than one sorted by date.

• CO-22 — May be covered by another payer
  The payer thinks somebody else is primary. Until coordination of benefits is corrected on their file, nothing on this claim will pay.
  Recovered by being fixed at coordination of benefits and rebilled. Matched from: “Coverage taken from whatever card the walk-in hands over at the desk and never checked against the plan, so the claim goes to a policy the patient left months ago”
• CO-45 — Charge exceeds the fee schedule
  A contractual write-off rather than a denial. It only becomes a problem when the allowed amount is wrong.
  Recovered by being checked against the contract before any work is done. Matched from: “A global urgent care case rate billed alongside a separate evaluation and management line where the contract pays one or the other, and the second line drops off”
• CO-252 — Additional documentation required
  The payer will not decide until it sees paperwork. Nothing happens until it arrives.
  Recovered by being answered with the document the payer names. Matched from: “Laceration repair paid at the simplest level because the note says the wound was closed but never records its length, its site or whether the closure was layered”
• CO-197 — Prior authorization absent
  The payer required prior authorization for this service and cannot find one attached to the claim.
  Recovered by being taken back to the authorization. Matched from: “Work injuries billed to the patient's health plan because nobody asked at registration, with no employer authorization or claim number on file”

Working a denied claim costs $57.23 per denied claim in administrative time (source), and about about 90% of initially denied claims are eventually paid. Most of what sits in a urgent care AR bucket is not lost money. It is money waiting for somebody with the hours to make the call.

Questions