Denied Claims and Delayed Payments: A Wake-Up Call for Urgent Care Billing

According to a recent industry report, up to 20% of medical claims are denied on the first submission, and approximately 65% of denied claims are never reworked. In urgent care settings, where margins are already tight and visit volumes are high, these numbers can translate into significant revenue loss. Furthermore, manual errors, poor coding, and missing patient data remain among the top causes of denials, many of which are avoidable.

Delayed payments add another layer of challenge. Many urgent care facilities report payment cycles stretching beyond 30 to 60 days, especially from commercial insurers. In fact, this delay can jeopardize their cash flow and long-term stability for centres that rely on timely reimbursements to manage staffing, supplies, and operational costs.

This situation is a clear wake-up call for urgent care administrators and billing teams. It is important to understand why claims are being denied and what causes payment delays as the first step toward implementing smarter billing practices. Let’s have a deep dive into all such reasons with proven strategies to overcome them.

How to Avoid Denied Claims and Delayed Payments in Urgent Care Billing?

Denied claims and delayed payments are two of the biggest problems urgent care centers encounter. Both can damage cash flow, boost administrative burden, and cause patient frustration. The following are some of the most frequent causes of claim denials and delays with ways to fix and prevent them.

• Outdated Coding

Using mismatched, incorrect, or outdated codes in urgent care billing may result in denials of the claim, reduced payments, or audits. This applies especially to CPT codes that are widely utilized in urgent care, like those for repairs of lacerations, rapid diagnostic testing, or administration of injections.

Regular training for your coding personnel regarding urgent care-specific CPT, ICD-10, and HCPCS code changes is a must. You can also implement a robust coding audit process and use coding software tools that reflect real-time code changes.

• No Follow-Up on Unpaid Claims

Unpaid claims can quickly pile up in urgent care facilities due to high patient volume and limited billing resources. Without a structured follow-up process, claims may remain unresolved and lead to lost revenue.

You should implement a tracking system that flags unpaid claims by payer, aging bucket, and denial reason. You should assign responsibility to billing staff for timely follow-up and rework denials using payer-specific resubmission procedures.

• Provider Credentialing Issues

Denials tend to happen when providers are not properly credentialed or enrolled with payers, especially in urgent care clinics where new and temporary staff are added to the team.

You must have a centralized re-credentialing and credentialing calendar to ensure that provider enrollment is up to date with all active payers. Further, perform a periodic audit of your billing system to ensure proper assignment of NPIs and TINs to all providers.

• Insurance Not Verified Properly

Failure to verify insurance coverage before providing services may result in delivering care that is not covered under the patient’s plan. This is most often discovered as denied claims and surprise out-of-pocket costs to patients.

You should have an active insurance verification system that confirms eligibility, copays, and authorization needs at service time. Further, utilize clearinghouse-integrated tools to automate verification and notify staff of issues with coverage ahead of time.

• Mismanaged Payer Contracts

Urgent care facilities tend to have several different payers with differing reimbursement schedules. Without ongoing review and renegotiation of contracts, claims are submitted at the incorrect rate or with unknown conditions, which will lead to denials or underpayments.

In order to avoid such mismanagement, negotiated fee schedules for urgent care services can be kept on all-payer contracts in a central database. You can also constantly update contract terms and ensure that your billing system has current allowable amounts for each payer.

• Lack of Knowledge About E/M Guidelines

Evaluation and Management coding errors are prevalent in urgent care due to under-documentation or inappropriate level selection. Such errors often lead to claim denials or low reimbursement.

You need to educate providers and billers regarding the 2021 E/M coding guidelines with emphasis on the correct selection of codes in terms of medical decision-making and time spent. In fact, periodic E/M audits can also be performed to ensure compliance and accuracy.

• Incomplete Patient Information

Urgent care facilities typically have high-volume patient intake, which creates more chances of incomplete or inaccurate demographic and insurance data capture. This leads to eligibility errors, denied claims, and delayed reimbursement.

Educate your front desk employees to correctly capture and verify all patient and insurance information at check-in. You may also use electronic verification tools to verify insurance eligibility and reduce manual data entry errors.

• Errors in Claim Forms

Mistakes on claim forms, such as incorrect Place of Service codes (for example, POS 20 for urgent care), billing provider mismatches, or omitted modifiers, may initiate rejections during payer scrubbing or lead to underpayment.

Use electronic billing systems with a built-in claim scrubbing feature to identify errors prior to submission. Also, train your billing staff on the specific documentation and coding rules that apply to urgent care billing.

• Wrong Billing of Temporary Providers

Temporary providers, or locum tenens, are common in urgent care but must be billed correctly. Mistakenly billing them as regular providers without appropriate modifiers can lead to compliance violations and claim denials.

You should educate your billing team on locum tenens billing rules, including the use of Modifier Q6 and CMS’s 60-day limit for temporary provider coverage. You should also monitor locum usage duration and maintain clear documentation for audits.

• Understaffed Billing Department

An overwhelmed billing team can lead to delays in claim submission, missed follow-ups, and an increase in billing errors. This directly impacts the revenue cycle and cash flow of an urgent care practice.

You should regularly assess billing workloads and ensure adequate staffing to handle patient volume. Outsource your urgent care billing and coding to experienced 24/7 Medical Billing Services familiar with urgent care billing requirements and denial management.

Is Outsourcing a One-Stop Solution?

In order to eliminate errors in billing and accelerate reimbursements, urgent care facilities may look to outsource to a reliable urgent care billing and coding company like 24/7 Medical Billing Services. Our experts with years of practice in urgent care billing guarantee accurate coding, on-time filing of claims, and aggressive follow-up on outstanding claims and denials. Our experienced team is aware of payer-specific rules, procedures specific to urgent care, as well as compliance guidelines. This will keep your facility financially sound and centered on patient care.

FAQs

Q1. Are urgent care services always covered under a patient’s insurance plan?

Some insurance plans may exclude certain urgent care services or require pre-authorization.

Q2. Is it necessary for urgent care centers to bill facility and professional fees separately?

In some cases, split billing is required based on the payer’s reimbursement structure and setup.

Q3.What role does telehealth play in urgent care billing?

Telehealth visits are billable for urgent care when compliant with payer rules and documented appropriately.

Q4. Can urgent care centers bill for follow-up care under the same visit?

Follow-up visits must be billed as separate encounters unless bundled under the payer policy.

Q5. Are there urgent care-specific clearinghouses for claim submission?

Some clearinghouses specialize in urgent care billing and offer tools tailored to high-volume practices.