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 orthopedics 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, from our office in Rawalpindi, Pakistan, logged into your own system on your hours. 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. Some payer contracts and some state Medicaid programs restrict or require disclosure of offshore access — check yours before placing a restricted queue on this seat (more on /security/).

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

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-27 — Coverage had already ended
  The patient was not covered on the date of service.
  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-109 — Wrong payer or contractor
  It went to the wrong place.
  Recovered by being fixed at coordination of benefits and rebilled. 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”
• CO-18 — Exact duplicate claim or service
  The payer already has this claim. Usually harmless, occasionally a sign that the original is stuck.
  Recovered by being checked against the original claim before any work is done. Matched from: “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”

Working a denied claim costs $57.23 per denied claim in administrative time (source), and payers ultimately pay roughly 90% of claims even while using an initial denial to slow payment. 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.

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